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MEDICAL  ANNALS 

of  the 

District  of  Columbia 


Official  Publication  of 

'I'he  Medical  Society  of  the  District  of  Columbia 


VOLUME  XXI 
1952 


EDITORIAL  BOARD 

Wallace  M.  Yater,  M.D.,  Editor 
Theodore  Wiprud,  Managing  Editor 
A.  Louise  Eckburg,  Assistant  Editor 
Roger  M.  Choisser,  M.D. 

Frank  D.  Costenbader,  M.D. 

Hugh  H.  Hussey,  Jr.,  M.D. 

Winfred  Overholser,  M.D. 

Herbert  P.  Ramsey,  M.D. 

R.  Lee  Spire,  M.D. 

Donald  Stubbs,  M.D. 

Joseph  S.  W all,  M.D.j 
Charles  Stanley  WMite,  M.D. 

EDITORIALOFFICE,  I7l8MS'l’REE'r,N.W.  WASHINGTOn6,D.C. 


t Died  September  18,  1952 


MEDICAL  ANNALS 

of  the 

DISTRICT  OF  COLUMBIA 


VOLUME  XXI  January,  1952  NUMBER  1 


FUNGUS  INFECTIONS  AND  THEIR  TREATMENT* 


^ V f^ANlFESTATIONS  of  disease 
due  to  fungi  which  are  most  commonly  encoun- 
tered are  those  associated  with  the  superficial 
fungus  infections.  Until  recently  the  incidence 
of  dermatophytosis  was  mainly  concerned  with 
the  fungus  infections  of  the  feet,  hands  and  groin. 
However,  the  picture  has  changed  to  a great 
extent  with  the  recent  epidemic  of  tinea  capitis. 

Incidence 

A number  of  men  have  investigated  the  prob- 
lem of  incidence.  The  largest  single  group  of 
cases  was  the  study  carried  out  by  the  U.  S. 
Public  Health  Service  in  the  years  1943-1944. ‘ 
Over  2,000  individuals  living  in  the  District 
of  Columbia,  New  Jersey,  Connecticut,  Indiana 
and  Louisiana  were  investigated  in  this  survey. 
There  was  a seasonal  fluctuation  in  clinical  evi- 
dence of  fungus  disease.  Dermatophytosis  af- 
fecting parts  of  the  body  other  than  the  hands 
and  feet  was  rarely  encountered.  In  that  study 
approximately  1,400  men  and  about  750  women 
were  examined.  Their  ages  ranged  from  17  to 
70  years,  but  most  of  those  examined  were  in 
the  second  and  third  decade  of  life.  Based  on 

* Address  delivered  before  the  Twenty-second  .\nnual  Scien- 
tific Assembly  of  the  Medical  Society  of  the  District  of  Co- 
lumbia, Oct  iber  2,  Ib.Sl. 


SAMUEL  M.  PECK,  M.D. 

Chief  of  the  Dermatological  Service,  Mount  Sinai  Hospital,  New 
York  City 


clinical  and  cultural  grounds,  the  classification 
of  the  examinees  were  as  follows:  positive,  590 
(27.79  per  cent);  doubtful,  714  (33.63  per  cent), 
and  negative,  819  (38.57  per  cent).  Classified 
according  to  sex,  of  1,393  men,  391  (28.06  per 
cent)  were  in  the  positive  group,  500  (35.89  per 
cent)  in  the  doubtful  group,  and  502  (36.03  per 
cent)  in  the  negative  group.  Of  733  women  ex- 
amined, 199  (27.2  per  cent)  were  in  the  positive 
group,  214  (29.31  per  cent)  were  in  the  doubt- 
ful group,  and  317  (43.42  per  cent)  were  in  the 
negative  group. 

Eight  per  cent  of  all  hospital  admissions  in  the 
armed  services  during  the  War  were  due  to 
cutaneous  diseases,  and  dermatophytosis  ran  sec- 
ond on  the  list.  Weidman-  and  his  associates 
believed  that  the  estimates  of  Peck  et  al  of  the 
incidence  of  clinically  active  dermatophytosis 
was  conservative.  They  believed  that  approxi- 
mately 65  per  cent  of  the  population  was  af- 
fected. Children  below  the  age  of  10  have  a very 
low  incidence  of  mycoses  of  the  feet. 

Although  the  work  of  Osborne  and  Hitch- 
cock^ seems  to  show  that  the  women  are  less 
affected  with  dermatophytosis  than  the  men, 
the  U.  S.  Public  Health  Service  surveys  did  not 
show  any  significant  difference  in  sex  incidence. 
It  will  be  shown  later  when  the  allergic  mani- 


1 


2 


Fungus  Infections — Peck 


JANUARY,  1952 


festations  of  the  fungi  are  discussed  that  prob- 
ably it  is  here  where  the  differences  in  opinion 
among  the  various  authors  can  be  explained. 

It  was  shown  by  cultural  study  that  some  pa- 
tients in  the  clinically  doubtful  group  had  true 
dermatophytosis.  There  was  no  significant  dif- 
ference in  sex  incidence.  When  the  same  per- 
sonnel were  examined  at  different  seasons  the 
number  of  clinically  negative  patients  rose  from 
13  to  19  per  cent  in  the  winter  to  54  per  cent  in 
the  summer.  Thus,  it  can  be  seen  that  there  is  a 
definite  influence  of  seasons  as  far  as  clinical 
evidence  of  the  activity  of  fungus  infections  is 
concerned. 

The  most  frequent  pathogenic  fungus  recov- 
ered was  T.  gypseum.  T.  purpureum  was  next 
in  frequency,  and  E.  inguinale  was  recovered 
from  an  occasional  case  only.  All  of  the  cultures 
of  T.  purpureum  were  recovered  in  one  locality. 

.\lthough  scalp  ringworm  has  always  been  en- 
demic in  a small  percentage  of  children  in  this 
country,  it  is  only  since  early  1942  that  it  be- 
came apparent  that  it  had  assumed  epidemic 
proportions.  The  epidemic  first  started  in  large 
eastern  centers  and  rapidly  spread  nationwide; 
although  it  has  decreased  somewhat,  it  is  still 
of  epidemic  proportions.  It  is  well  established 
that  shortly  after  puberty  in  the  majority  of 
cases  tinea  of  the  scalp  disappears  spontaneously. 

Thousands  of  cases  of  tinea  capitis  have  been 
examined  in  the  last  few  years  and  the  causative 
fungus  isolated.  Most  observers'*  have  noted  that 
M . audouini  and  M.  lanosum  were  responsible 
for  nearly  all  of  the  cases  of  ringworm  of  the 
scalp.  However,  the  majority  of  oliservers  agree 
that  all  but  a few  of  the  patients  in  the  present 
epidemic  were  found  to  be  infected  by  M. 
audouini.  The  scalp  ringworm  due  to  a micro- 
sporon  of  animal  type  like  M.  lanosum  is  asso- 
ciated in  a large  percentage  of  cases  with  sensiti- 
zation to  the  fungus.  The  human  type  of  micro- 
sporon  like  M.  audouini  is  much  more  resistant 
to  local  therapy  because  of  the  lack  of  accom- 
panying sensitization. 


In  a recent  study  of  the  6,598  pupils  of  grade 
and  junior  high  schools  in  Hagerstown,  Mary- 
land, approximately  8.3  per  cent  were  discovered 
to  have  ringworm  of  the  scalp,  nearly  all  due  to 
M.  audouini.'^  During  the  period  of  the  study, 
August  1944  to  November  1945,  the  number  of 
boys  infected  was  12.1  per  cent  of  the  boys  ex- 
amined; the  number  of  girls  infected  was  2.1 
per  cent  of  the  number  of  girls  examined.  Most 
of  those  affected  were  under  12  years  of  age. 

Allergic  Manifestations  Dlte  to  Fungi 

The  clinical  manifestations  caused  by  both 
bacteria  and  fungi  can  be  divided  roughly  into 
2 large  groups:  those  which  are  directly  due  to 
these  organisms  and  those  special  forms  which 
have  arisen  because  of  the  development  of  sen- 
sitization to  the  organisms  and/or  their  products. 
These  last  manifestations  have  been  grouped 
under  the  heading  of  cutaneous  microbids. 

The  clinical  manifestations  of  microbids  de- 
pend on  development  of  acquired  hypersensitiv- 
ity to  the  organisms  and  ^or  their  products  after 
the  primary  infection  has  existed  for  some  time. 
The  degree  of  acquired  hypersensitivity  is  de- 
pendent on  the  causative  organism,  on  individual 
predisposition,  and  on  many  other  factors  which 
cause  more  intimate  contact  between  the  living 
organisms  and  the  living  cells. 

In  the  group  of  microliids,  we  have  trichophy- 
tids  when  the  trichophyton  fungus  is  the  pri- 
mary cause  of  the  lesion,  epidermophytids  when 
an  epidermophyton  is  the  causative  organism, 
and  levurids  when  monilia  cause  the  primary 
infection.  Trichophytidsis  the  general  term  which 
has  been  applied  to  the  microbid  associated 
with  fungus  infections.  The  term  in  the  litera- 
ture has  often  been  shortened  to  “ids.” 

The  allergic  manifestations  due  to  fungi  which 
are  most  commonly  encountered  are  those  asso- 
ciated with  the  superficial  fungus  infections.  Of 
these,  almost  all  are  associated  with  infection 
due  to  T.  mentagrophytes,  especially  dermato- 
phytosis of  the  feet. 


VOL.  XXI,  NO.  1 


Medical  Annals  of  the  District  of  Columbia 


3 


Pathogenesis  of  Trichophytids 

The  epidermophyton  and  trichophyton  fungi 
grow  in  the  nonliving  layers  of  the  skin  and  its 
appendages.  Because  of  this  fact  they  give  rise  to 
clinical  manifestations  which  are  primarily  of  a 
very  superficial  nature.  Marked  inflammation 
does  not  develop  unless  living  structures  are  in- 
vaded. Invasion  by  the  fungi  of  living  structures 
or  contact  of  fungi  or  their  products  with  the 
living  parts  of  the  skin  probably  initiate  the  hy- 
persensitivity with  its  resulting  allergic  mani- 
festations. 

A sine  qua  non  for  the  development  of  tri- 
chophytids is  a hypersensitivity  to  fungi  or  their 
products.  This  sensitivity  is  revealed  by  a posi- 
tive trichop hy tin  reaction.  Fortunately  the  tri- 
chophytin  test  represents  a group  reaction  in  the 
majority  of  instances.  This  means  that  the  test 
does  not  usually  have  to  be  made  with  the  iden- 
tical fungus  causing  the  lesions.  Previously  it  was 
thought  to  be  present  only  in  the  deep  inflamma- 
tory fungus  infections  such  as  kerion  celsi.  Re- 
cently, however,  it  has  been  demonstrated  that 
even  superficial  fungus  diseases  were  frequently 
accompanied  by  sensitivity  to  trichophytin.  The 
hypersensitivity  to  fungi  develops  after  the  pri- 
mary infection  has  existed  for  some  time.  The 
period  between  onset  of  infection  and  the  de- 
velopment of  hypersensitivity  varies  from  a few 
months  to  several  years,  depending  on  the  type 
of  fungus,  the  site  of  the  primary  infection,  and 
the  infected  individual. 

It  is  very  dilficult  to  determine  whether  atopy 
plays  a role  in  the  development  of  this  hyper- 
sensitivity. In  the  available  statistical  data  a 
history  of  atopy  seems  rather  unimportant,  es- 
pecially as  far  as  the  epidermophytids  on  the 
hands  are  concerned. 

If  we  were  to  assume  that  not  only  the  fungi 
but  also  their  toxins  can  give  rise  to  tricho- 
phytids, it  would  be  easy  to  understand  why 
trichophytids  are  usually  sterile.  Such  an  as- 
sumption, however,  would  not  explain  the  localiza- 
tion of  epidermophytids  on  the  hands  only,  sec- 
ondary to  the  fungus  infection  of  the  feet  in  the 


presence  of  a generalized  skin  sensitivity.  Fur- 
thermore, it  has  not  been  possible  to  demonstrate 
such  circulating  toxins  while  positive  blood  cul- 
tures for  fungi  identical  with  those  causing  the 
primary  infection  have  been  obtained. 

It  is  within  the  realm  of  theoretical  possibil- 
ities that  contact  with  primary  lesions  can  cause 
transportation  of  the  organisms  to  other  parts 
of  the  body  and  give  rise  to  trichophytids  by 
contact.  The  eruptive  character  of  most  of  the 
microbids  speaks  against  such  a conception.  Such 
a possibility  must  be  borne  in  mind,  however, 
when  nonsymmetrical  isolated  lesions  are  found 
which  are  considered  to  be  trichophytids,  es- 
pecially those  in  which  the  organisms  are  more 
readily  demonstrated.  It  is  even  conceivable  that 
organisms  of  great  virulence  can  reach  areas  of 
skin  hematogenously  and,  in  the  presence  of  a 
moderate  degree  of  hypersensitivity,  pass 
through  all  barriers  to  give  rise  to  lesions  which 
are  real  secondary  foci  of  epidermophytosis  (tri- 
chophytosis) . 

There  are  certain  experimental  and  clinical 
criteria  which  must  be  present  to  support  the 
diagnosis  of  “ids.”  Such  criteria  are  as  follows: 

1.  The  causative  organism  must  be  demon- 
strated in  what  is  recognized  by  everyone  as  a 
classical  manifestation  of  the  disease. 

2.  Mthough  it  is  not  absolutely  essential,  the 
organism  which  is  cultured  from  the  primary 
lesion  should  be  pathogenic. 

3.  A positive  reaction  analogous  to  a tuberculin 
or  a trichophytin  reaction  must  be  present. 

4.  What  is  considered  to  be  microbid  should 
be  seen  as  a frequent  accompaniment  of  the 
primary  lesion. 

5.  Positive  blood  cultures  for  the  same  organ- 
ism isolated  from  the  primary  lesion  must  be 
obtained,  since  it  is  admitted  that  most  of  the 
microbids  are  hematogenous  eruptions.  This  is 
necessary  because  there  is  no  reliable  method  of 
demonstrating  the  presence  of  circulating  toxins. 

6.  The  microbids  must  develop  subsequent  to 
the  primary  infection. 

7.  The  microbids  must  usually  be  sterile. 


4 


Fungus  Infections — Peek 


JANUARY,  1952 


8.  A support  for  the  conception  of  a skin  erup- 
tion as  an  “id”  lies  in  certain  clinical  character- 
istics: (a)  appearance  of  the  “ids”  in  showers, 
(b)  tendency  to  symmetry  in  distribution  because 
of  hematogenous  origin,  (c)  tendency  to  spon- 
taneous involution  after  healing  of  the  primary 
focus,  and  (d)  focal  reactions  after  injection  of 
sufficient  amounts  of  microbidin. 

Although  it  is  true,  as  is  the  rule  for  other 
microbic  diseases,  that  different  fungi  can  elicit 
the  same  clinical  picture  and  that  totally  different 
skin  manifestations  can  be  found  associated  with 
the  same  fungus,  it  was  found,  fortunately,  that 
in  the  majority  of  instances  we  could  associate 
the  various  types  of  trichophytids  with  certain  - 
of  the  primary  fungus  diseases.  Thus,  the  lichen 
trichophyticus  usually  accompanied  markedly  in- 
flammatory fungus  infection  such  as  kerion  celsi 
(trichophytosis),  while  the  dyshydrotic  eruptions 
of  the  hands  were  usually  found  associated  with 
the  epidermophyton  infection  of  the  feet. 

The  localization  of  the  embolized  fungi  and  the 
site  of  greatest  skin  sensitivity  play  an  important 
part  in  the  morphology  of  the  resulting  tri- 
chophytid.  If  the  organisms  finally  become  local- 
ized in  the  vasa  vasorum  of  the  subcutis,  a 
subcutaneous  trichophytid  (erythema  nodosum) 
develops;  if  they  become  localized  in  the  vessels 
of  the  hair  follicle,  lichenoid  forms  result;  if  the 
epidermis  is  a special  site  of  sensitivity,  eczema- 
toid  trichophytids  are  found;  and,  if  the  hyper- 
sensitive organism  is  flooded  with  to.xins,  diffuse 
scarlatiniform  eruptions  are  seen. 

'Fypes  of  Tricophytids 

.\s  can  be  seen  from  table  1,  the  trichophytids 
can  be  classified  under  4 headings,  depending 
on  their  histologic  and  clinical  characteristics. 
The  epidermal  and  cutaneous  types  are  the  most 
common.  The  lesions  under  group  IV  have  been 
recognized  only  lately  as  trichophytids,  and  I 
have  observed  several  cases  in  which  the  recur- 
rent phlebitis  seems  to  be  accompanied  by  other 
vascular  sensitivities,  even  epileptiform  seizures. 
No  doubt  the  most  important  and  fre(]uent  tri- 


chophytid observed  is  that  accompanying  epi- 
dermophytosis. The  epidermophytosis  is  usually 
on  the  feet,  while  the  epidermophytids  are  on  the 
hands.  The  essential  proofs  for  their  relation- 
ship, as  laid  down  in  previous  paragraphs,  have 
been  well  established  in  this  important  group  by 
the  work  of  Peck  and  Jadassohn.®  Even  such 
difficult  evidence  as  positive  blood  cultures  for 
fungi  has  been  presented  by  Peck,®  Strickler, 
Ozellers,  and  Saletel.  Furthermore,  Peck  has  been 

TABLE  1 

Types  of  Trichophytids 

I.  Epidermal  trichojrhytids  (epidermis  mainly  involved) 

1.  Eczematoid  (dyshydrotic) 

2.  Lichenoid 

3.  Parakeratotic 

4.  Psoriasiform 

11.  Cutaneous  trichophytids  (papillary  body  mostly  in 

volved) 

t.  Diffuse  forms 

a.  Scarlatiniform  exanthemata  and  enanthemata 

b.  Erythroderma 

2.  Circumscribed  and  disseminated  forms 

a.  Follicular  localizations  usualh’  lichenoid 

b.  Not  exclusively  follicular 

(1)  Macular,  ])apular  and  even  exudative 
erui)tions 

c.  Erysii)eloid 

in.  Subcutaneous  trichophytids  (nodules  found  in  the 

hyiroderm  of  the  tyi)e  of  erythema  nodosum) 

1 . .\cute  resolving  form 

2.  Destructive  chronic  form 

I\'.  Vascular  tricho|)hytids 

1.  Migrating  phlebitis  (venous) 

2.  Urticaria  (capillary) 

3.  Purpuric 

able  to  reproduce  the  whole  clinical  syndrome 
e.xperimentally  in  humans.  This  was  the  first 
time  that  a spontaneous  experimental  tricho- 
phytid had  been  reproduced  in  a human  sub- 
ject. 

Recent  literature,  both  foreign  and  American, 
has  become  increasingly  filled  with  the  discus- 
sion of  levurids,  those  mycids  which  are  due  to 
monilia.  Ravaut,  a jrupil  of  Sabouraud,  described 
the  first  cases.  Very  interesting  examples  of  such 
eruptions  have  been  dimionstrated  by  Ramel, 


VOL.  XXI,  NO.  1 


Medical  Annals  of  the  District  of  Columbia 


0 


Hopkins  and  others.’^  As  Bloch*  has  pointed  out, 
in  discussing  the  research  of  Staehelin  from  his 
Institute,  it  is  very  difficult  to  prove  that  an 
eruption  is  a levurid.  One  of  the  chief  stumbling 
blocks  seems  to  be  to  prove  a pathogenic  role  for 
monilia  cultured  from  what  is  called  the  primary 
lesions. 

The  importance  of  monilia  and  their  allergic 
manifestations  are  becoming  increasingly  evi- 
dent. This  is  so  because  there  is  an  apparent 
rise  in  the  growth  of  monilia  following  the  in- 
gestions of  many  of  the  antibiotics,  especially 
the  mycins  such  as  aureomycin,  terramycin,  etc. 

To  obtain  an  appro.ximate  idea  of  the  incidence 
of  trichophytin  sensitivity  and  the  importance 
of  the  trichophytin  test  as  an  inde.x  of  this  sen- 
sitivity, in  1944  Peck  and  his  group  studied  776 
persons  living  in  different  sections  of  the  country. 
Of  these,  about  42.53  per  cent  had  a reaction 
which  varied  from  1 to  4 plus.  It  was  interesting 
to  note  that  of  the  558  males  tested,  48  per  cent 
showed  a positive  reaction,  while  of  the  218  fe- 
males tested,  29.96  showed  a positive  reaction. 
.\pparently,  as  has  been  shown  in  further  work, 
there  is  a sex  linkage  in  the  development  of  sen- 
sitivity to  fungus  antigen.  Lewis  and  Hopper® 
in  their  work  found  that  60  per  cent  of  their 
patients  infected  with  T.  gypseum  showed  a posi- 
tive reaction  to  trichophytin.  The  number  of  tri- 
chophytin reactions  rose  to  87  per  cent  when 
definite  clinical  activity  was  present.  The  stud- 
ies of  Peck  and  his  group  showed  a similar  rise 
both  in  incidence  and  intensity  of  the  trichophy- 
tin test  when  active  fungus  infection  was  present. 
In  another  study  conducted  in  1948  Peck  and 
his  group  examined  406  adults  living  in  and 
around  New  York.  Of  these,  27.4  per  cent  were 
found  to  be  positive  to  trichophytin.  The  250 
males  studied  showed  36.9  per  cent  to  have  posi- 
tive reactions,  and  the  156  females  studied  had 
positive  reactions  in  only  14.2  per  cent.  'I'his  is 
in  line  with  the  studies  they  published  in  1944. 
.About  100  children  were  studied  under  12  years 
of  age  for  trichophytin  sensitivities,  and  there 
were  no  positive  reactions  in  any  of  this  grouj). 


Trichophytin  may  be  defined  as  an  extract  of 
fungi  which  is  used  both  for  diagnosis  and  treat- 
ment. It  has  been  firmly  established  by  many 
investigators  since  the  original  preparation  of 
trichophytin  in  1902  by  Plato  and  Neisser  that 
the  positive  reaction  following  the  intracutaneous 
administration  of  this  substance  is  due  to  a spe- 
cific sensitivity  resulting  from  a fungus,  that  is, 
a trichophyton  infection. 

Fungi  of  the  epidermophyton,  trichophyton 
and  other  genera  contain  a general  sensitizing 
factor,  so  that,  as  stated  previously,  a patient 
infected  with  a trichophyton,  in  whom  a hy- 
persensitivity has  developed,  will  show  a posi- 
tive trichophytin  reaction  with  an  extract  made 
from  any  of  these  organisms.  According  to  Jadas- 
sohn, Schaaf,  and  Laetsch  there  is  an  additional 
specie-specific  excitant  which  may  not  be  pres- 
ent in  any  other  members  of  the  group.  Because 
the  reaction  of  sensitivity  may  be  limited  to  this 
specific  excitant,  one  may  occasionally  obtain  a 
negative  reaction  to  a trichophytin  test  even  in 
the  presence  of  “ids,”  if  the  specific  trichophytin 
used  lacks  this  substance. 

Trichophytin,  as  it  is  commercially  available, 
is  a complex  material,  probably  containing  a 
number  of  different  antigens,  the  potency  of 
which  is  dependent  to  a great  extent  on  the 
method  of  preparation. 

Peck  and  Glick'"  in  a series  of  experiments  were 
able  to  show  that  the  skin-reactive  factor  which 
is  responsible  for  the  elicitation  of  a positive 
cutaneous  reaction  to  trichophytin  is  found  in 
both  the  bouillon  and  the  pellicle  of  a culture  of 
T.  gypseum  on  Sabouraud’s  bouillon.  This  skin- 
reaction  factor  could  be  demonstrated  to  be 
present  in  the  pellicle  from  the  latter’s  earliest 
appearance.  In  their  experiments,  enough  j)ellicle 
material  could  be  gathered  in  7 days  to  demon- 
strate this  specific  factor.  Such  concentrations 
remained  at  approximately  the  same  level 
throughout  the  whole  period  of  the  experiment, 
that  is,  66  days. 

In  the  bouillon,  however,  the  concentration  of 
th(‘  skin-reactive  factor  increased  with  the  age 


6 


Fungus  Infections — Peck 


JANUARY,  1952 


of  the  culture  under  ordinary  growth  conditions. 
It  could  be  demonstrated  to  be  present  in  7 days, 
but  it  reached  its  maximum  concentration  in  40 
to  50  days  under  varied  experimental  conditions. 

T.  purpureum  formed  less  skin-test  principles 
than  T.  gypseum  under  the  same  experimental 
conditions.  This  is  of  interest  since  it  is  known 
that  infection  with  T.  purpureum  is  usually  not 
associated  with  a positive  trichophytin  test.  The 
total  nitrogen  content  of  trichophytin  was  found 
to  bear  no  relation  to  the  amount  of  skin-test 
factor  present  in  bouillon. 

Peck  and  Hewitt"  in  1945  were  apparently 
able  to  demonstrate  that  several  members  of  the 
group  of  fungi  occurring  in  clinical  lesions  of 
dermatophytosis  were  found  to  elaborate  a fac- 
tor antagonistic  to  certain  other  microorganisms. 
This  factor  appeared  to  be  similar  to  penicillin 
in  the  following  respects:  (a)  enhanced  produc- 
tion on  media  containing  corn-steep  liquor;  (b) 
spectrum  of  activity  and  behavior  toward  peni- 
cillin-resistant organisms;  (c)  sensitivity  to  pH 
and  temperature,  and  (d)  destruction  by  clorase. 

Relationship  between  Fungus  Infections 
AND  Penicillin  Sensitivity 

So  far  it  is  apparent  that  fungus  antigens  play 
an  important  role  in  eliciting  allergic  manifesta- 
tions in  the  general  population  both  because  of 
the  high  incidence  of  fungus  infection  and  be- 
cause a relatively  large  number  of  those  infected 
acquire  a sensitivity  to  the  fungi  and/or  their 
products.  With  the  introduction  of  the  anti- 
biotics into  therapeutics,  however,  the  impor- 
tance of  the  fungus  antigens  as  causes  of  allergic 
reaction  has  immeasurably  increased. 

The  clinical  reactions  to  penicillin  are  of  2 
major  types:  reaction  of  the  urticarial,  serum- 
sickness-like  type,  and  reactions  with  an  ery- 
themato-vesicular  eruption  resembling  the  tri- 
chophytids.*^ 

The  urticaria  and  erythemas,  together  with 
joint  pain,  and  fever  in  some  instances,  comprise 
the  commonest  allergic  reactions  to  penicillin. 
The  induced  urticarial  form  of  penicillin  allergy 


is  often  temporary,  even  transient  in  character. 
This  is  an  induced  sensitivity  and  requires  a 
definite  incubation  period  varying  from  5 days 
to  3 weeks.  In  a recent  study  by  Peck  et  ab^  it 
was  shown  that  among  130  patients  who  received 
penicillin  there  were  25,  or  about  19  per  cent, 
who  exhibited  such  an  acquired  sensitivity.  In 
approximately  40  per  cent  of  those  developing 
this  sensitivity  a positive  penicillin  test  of  the 
delayed  type  could  be  elicited.  Previous  fungus 
disease  is  not  considered  to  have  played  a role  in 
this  form  of  induced  sensitivity. 

Penicillin  reactions  of  the  erythemato-vesic- 
ular  type  resemble  trichophytids.  This  form  of 
penicillin  sensitivity  may  be  conceived  of  as 
existing  in  a latent  and  active  stage.  The  latent 
stage  is  characterized  simply  by  the  presence  of 
a positive  48-hour  penicillin  skin  test  without  any 
history  of  previous  penicillin  administration.  At- 
tention to  the  so-called  “spontaneous”  positive 
skin  test  was  first  drawn  by  Welch  and  Rosten- 
berg.iu  14  xhe  active  stage,  based  upon  the  pre- 
existing latent  sensitivity,  appears  after  exposure 
to  penicillin  and  resembles  the  trichophytid  be- 
cause it  is  characterized  by  an  erythemato-vesic- 
ular  eruption  which  tends  to  localize  primarily 
on  the  hands,  feet  and  groins,  but  may  become 
generalized. 

Among  276  adults  who  had  not  received  peni- 
cillin there  was  an  incidence  of  5.4  per  cent  with 
a positive  delayed  reaction  to  pencillin.  Welch 
and  Rostenberg^^  " in  a small  series  tested  found 
an  incidence  of  5 per  cent.  Sixty-five  children 
below  12  years  of  age  were  tested  and  none 
showed  a positive  reaction.  Similar  observations 
were  reported  by  Cormia  and  Lewis. 

The  work  of  Peck  and  Hewitt  e.xplains  the 
mechanism  by  which  dermatophytons  may  in- 
duce a positive  penicillin  test  and  ultimately  lead 
to  reactions  to  penicillin  which  resemble  those  of 
the  trichophytids.  The  results  of  their  investiga- 
tions, as  previously  cited,  showed  that  the  com- 
mon pathogenic  fungi  mainly  responsible  for 
many  of  the  dermatomycoses  are  capable  of 
producing  an  antibiotic  possessing  many  of  the 


VOL.  XXI,  NO.  1 


Medical  Annals  of  the  District  of  Columbia 


7 


properties  of  penicillin.  In  the  course  of  a fungus 
infection  of  the  skin  there  are  a number  of  anti- 
gens elaborated  by  the  infectious  agent.  One 
of  those  is  responsible  for  the  positive  tricho- 
phytin  test  and  trichophytin  sensitivity,  and 
another  leads  to  the  so-called  “spontaneous” 
penicillin  test  and  represents  the  latent  phase  of 
penicillin  sensitivity. 

The  relationship  of  the  incidence  of  the  “spon- 
taneous” positive  penicillin  test  to  the  trichophy- 
tin reaction  is  of  interest.  The  trichophytin  test 
carried  out  simultaneously  in  the  patients  who 
have  not  received  penicillin  treatment  showed 
positive  reactions  in  33.3  per  cent.  Among  the 
penicillin-positive  patients  there  were  60  per  cent 
who  had  showed  a positive  trichophytin  reac- 
tion, practically  twice  as  frequently  as  among 
penicillin-negative  individuals.  Furthermore,  the 
percentage  of  patients  sensitive  to  penicillin 
among  trichophy tin-positive  individuals  was  9.7 
per  cent  as  against  3.2  per  cent  among  tricho- 
phytin-negative  persons.  Additional  evidence  of 
the  relationship  between  previous  fungus  in- 
fection of  the  skin  and  trichophytin  sensitivity 
on  the  one  hand  and  “spontaneous”  penicillin 
sensitivity  on  the  other,  is  found  in  our  observa- 
tions on  165  children  ranging  in  age  from  2 
months  to  12  years  who  had  never  received  peni- 
cillin. In  none  of  these  was  either  the  penicillin 
or  trichophytin  test  positive.  These  negative 
findings  are  in  accord  with  the  known  fact  that, 
even  if  present,  fungus  infections  in  the  form  of 
dermatophytosis  rarely  produce  sensitivity  to 
trichophytin  in  children  below  12  years  of  age. 

It  has  been  shown  that  in  spite  of  practically 
the  same  incidence  of  fungus  infection  among 
males  and  females  there  was  a much  higher  per- 
centage of  males  who  acquired  a sensitivity  than 
females.  This  trend  also  applies  to  penicillin 
sensitivity.  Among  130  patients  who  received 
penicillin  there  were  32  with  skin  eru{)tions, 
34.2  per  cent  of  all  males  developing  them  as 
against  only  8.3  per  cent  of  females. 

.'\mong  276  adults  whom  we  treated  who  had 
never  received  penicillin,  there  were  164  males, 
of  whom  6.05  per  cent  showed  the  so-called 


“spontaneous”  positive  reaction.  Of  108  females 
only  4,  or  3.7  per  cent,  showed  a positive  reac- 
tion. 

The  active  stage  of  penicillin  sensitivity  occurs 
during  treatment.  Unlike  the  induced  form,  this 
reaction  can  occur  on  the  first  day  or  two  or  even 
on  the  first  administration  of  penicillin.  We  had 
7 such  cases.  All  were  males,  and  the  trichophy- 
tin and  penicillin  tests  were  positive  in  each  case. 
The  much  higher  incidence  of  positive  penicillin 
and  trichophytin  tests  in  this  group  than  in  the 
urticarial  form  of  reaction  is  indicative  of  pre- 
e.xisting  sensitivity  and  its  relation  to  fungus 
disease.  Patients  with  this  type  of  penicillin  sen- 
sitivity usually  have  persistent  penicillin  allergy 
of  varying  degrees.  There  is  no  common  antigen 
between  crystalline  penicillin  and  trichophytin. 

Treatment  of  Fungus  Infections 

Dermatophytosis  of  the  hands  and  feet.  When 
there  are  acute  manifestations  with  vesiculation 
and  eczematization,  unless  it  is  due  to  previous 
treatment  it  can  be  assumed  in  the  majority  of 
cases  of  dermatophytosis  of  the  hands  and  feet 
that  there  is  a fairly  high  degree  of  sensitivity 
to  the  fungi  present.  This  can  be  demonstrated 
by  the  trichophytin  test.  Under  such  circum- 
stances, only  the  mildest  treatment  is  indicated. 
Even  when  there  is  a chronic  fungus  infection  of 
the  feet  with  a high  degree  of  trichophytin  sensi- 
tivity, the  use  of  strong  fungicidal  preparations 
is  to  be  avoided  since  it  can  precipitate  “ids.” 

In  the  acute  stages  soakings  in  warm  potassium 
permanganate  footbaths  (1:8,000  to  1:16,000) 
for  15  minutes  twice  a day  or  the  use  of  3 to 
5 per  cent  sodium  propionate  footbaths  are  very 
helpful.  Sopronol  liquid  can  be  used  in  the  same 
way  (1  teaspoonful  to  1 quart  of  water)  for  the 
footbath  if  the  sodium  proj)ionate  powder  is  not 
available. 

It  is  not  uncommon  in  the  acute  stages  to  have 
secondary  infection  with  actual  pustular  forma- 
tion. .\  simj)le  method  of  treatment  here  is  the 
application  of  wet  dressings  of  J or  \ per  cent 
silver  nitrate  solution  or  wet  dressings  with  ter- 
ramycin  or  one  of  the  other  antibiotics  other 


8 


Fungus  Infections — Peck 


JANUARY,  1952 


than  penicillin  can  be  tried.  If  the  acute  mani- 
festations are  less  evident,  antiseptic  ointments 
in  the  form  of  aureomycin,  terramycin  or  a prep- 
aration containing  bacitracin  or  tyrothricin  can 
be  used.  Once  the  acute  manifestations  are  over, 
it  is  recommended  that  one  of  the  fatty  acid- 
containing  ointments  be  used  since  they  are  less 
likely  to  precipitate  “ids.”  Such  ointments  are 
exemplified  by  preparations  like  Sopronol  and 
Desenex.  If  there  is  a high  degree  of  sensitivity, 
even  these  ointments  should  be  used  in  one- 
half  or  one-third  strength  with  petrolatum.  If 
improvement  takes  place,  a tincture  such  as  one 
of  the  following  can  be  tried: 


Sodium  propionate 

Cm. 

10.0 

Salicylic  acid 

3.0 

Menthol 

1.0 

Phenol 

1.0 

.Alcohol  f|.s.  ad 

100.0 

or 

Castellani’s  paint 

The  formula  for  Castellani’s  paint  is  as  follows: 


Cm. 

.Saturated  alcoholic  solution  basic  fuchsin  10.0  (10%) 

.\queous  solution  ijhenol  (5%)  100.0 

Filter  and  add  : 

Boric  acid  1.0  (1%) 

.After  2 hours,  add: 

•Acetone  5.0  (5%) 

Resorcin  10.0(10%) 


In  the  chronic  eczematoid  cases  it  may  be 
necessary  even  to  use  a mild  tar  ointment  at  some 
stages  during  treatment. 

In  the  chronic  resistant  cases  which  are  ex- 
emplified in  infections  such  as  those  due  to  T. 
purpureum  it  may  be  necessary  to  use  very 
strong  fungicidal  remedies.  This  is  so  because 
those  infections  are  usually  not  accompanied  by 
sensitivity  to  the  fungi,  and  their  products  and 
the  precipitation  of  “ids”  is  very  unlikely.  In 
those  cases,  Arning’s  tincture,  if  obtainable,  is 
very  useful,  or  preparations  such  as  ^ per  cent 
chrysarobin  in  zinc  paste  or  3 per  cent  chrysaro- 
bin  in  chloroform  may  have  to  be  tried. 


Lesions  recognized  as  trichophytids  will  grad- 
ually disappear  once  the  primary  focus  is  treated. 
However,  when  they  are  present  they  should  be 
treated  as  any  dermatitis,  but  the  use  of  fungi- 
cides is  not  only  not  necessary  but  is  contra- 
indicated. In  such  cases  the  use  of  mild  wet  dress- 
ings, mild  ointments  and  small  doses  of  X-rays 
are  sometimes  very  helpful.  Here,  if  there  is 
doubt  whether  one  is  dealing  with  trichophytids 
or  actual  fungus  infections,  especially  with  ecze- 
matoid lesions  on  the  hands,  the  fatty  acid  oint- 
ments such  as  Sopronol  or  Desenex  in  half 
strength  will  not  irritate  and  will  act  as  a mild 
soothing  preparation. 

The  majority  of  authors  who  have  written  on 
this  subject  in  the  last  few  years  have  been 
unanimous  in  their  opinion  that  desensitization 
with  trichophytin  has  been  of  relatively  little 
value.  This  is  not  quite  true.  As  has  been  stated 
previously,  it  is  not  that  the  theoretical  and  prac- 
tical applications  of  this  form  of  treatment  have 
been  proven  valueless,  but  that  the  commercially 
available  extracts  leave  much  to  be  desired. 

In  cases  of  chronic  recurrent  eczematoid  der- 
matophytids,  it  is  sometimes  most  valuable  to 
use  trichophytin  properly,  and  it  has  proved  to 
be  invaluable  in  many  cases.  The  important 
fact  to  remember  is  that  the  trichophytin  test 
must  produce  of  itself  an  eczematoid  reaction 
and  the  desensitization  should  be  carried  past  the 
point  where  injections  of  1:10  concentration  of 
trichophytin  used  fail  to  elicit  any  sort  of  local 
reaction. 

1 have  used  a trichophytin  made  in  my  own 
laboratories  and  in  certain  cases  made  from  the 
fungus  isolated  from  the  patient  in  question. 

I'inea  capitis.  It  is  absolutely  essential  in  this 
disease  that  an  attempt  be  made  to  isolate  the 
fungus  causing  it  in  order  that  a prognosis  can 
be  given.  The  Wood’s  light  gives  us  a rapid 
diagnosis,  since  with  this  instrument  a brilliant 
green  fluorescence  is  found  when  the  common 
fungi,  that  is,  M . audouini  and  M . lanosum,  are 
the  etiologic  factors.  Cultures  are  important  be- 
cause the  animal  type  of  ringworm,  that  is,  M. 


VOL.  XXI,  NO.  1 


Medical  Annals  of  the  District  of  Colubmia 


9 


lanosnm,  usually  is  much  more  amenable  to  local 
treatment.  Treatment  can  be  divided  as  follows: 

In  sporadic  cases  there  is  no  doubt  that  the 
most  valuable  approach  to  the  treatment  of 
tinea  of  the  scalp,  especially  in  the  type  due  to 
M . audoiiini,  is  X-ray  epilation.  This,  of  course, 
is  to  be  carried  out  by  a specialist  in  order  to 
avoid  permanent  baldness.  It  is  important  even 
in  these  cases  to  follow  up  the  treatment  with  the 
use  of  the  proper  local  antiseptics  once  the  hair 
has  fallen  out. 

In  epidemic  cases,  because  of  the  large  num- 
ber of  cases  involved,  it  is  impractical  and  even 
impossible  to  attempt  X-ray  epilation  as  the 
treatment  of  choice.  In  addition,  there  is  a prob- 
lem of  the  epidemic  itself  which  must  be  con- 
sidered. For  this  reason,  the  following  recom- 
mendations are  made: 

1.  If  the  health  authorities  agree,  infected 
children  should  not  be  kept  away  from  school. 
However,  each  infected  child  must  have  the  hair 
clipped  close  to  the  scalp  and  kept  short  by  clip- 
ping the  hair  every  10  days.  Loose  hairs  may  act 
as  foci  of  infection.  The  parents  should  be  in- 
structed to  examine  the  headgear  of  the  children, 
especially  the  boys,  since  old  infected  hairs  may 
be  present  to  act  as  foci  of  reinfection. 

2.  The  parents  must  be  warned  of  the  role  of 
the  barber  shop  as  a possible  focus  of  infection. 
They  should  insist  that  the  barber  sterilize  his 
equipment  before  cutting  the  child’s  hair.  If 
the  barber  is  not  equipped  for  special  sterilizing 
methods,  such  as  keeping  the  instruments  in 
oil  at  10()°C.,  a simple  method  consists  in  the  use 
of  a 1 per  cent  solution  of  lysol  or  liquor  cresolis 
saponatus  USP  at  100°C.,  which  will  sterilize 
instruments  within  2 minutes. 

3.  The  children  should  be  examined  under  the 
Wood’s  light,  and  the  areas  of  fluorescence 
pointed  out  to  the  parents  and  marked  off  with 
a skin  pencil,  and  the  parents  should  be  in- 
structed to  treat  these  areas  especially  well. 

4.  While  under  treatment  the  child  should 
wear  a close-fitting  skull  cap  at  all  times.  Such 
caps  are  to  be  worn  in  the  classroom.  Fach 


child  should  have  at  least  4 or  5 caps.  The  cap 
should  be  changed  daily  and  boiled  for  10  min- 
utes before  washing.  Only  one  person  should 
remove  the  skull  cap. 

The  following  are  the  recommended  forms  of 
local  treatments: 

a.  The  head  is  shampooed  before  each  visit  to 
the  doctor. 

b.  There  is  used  as  a local  treatment  a number 
of  recommended  ointments,  such  as  propionate- 
caprylate  ointment,  copper  undecylinic  acid  oint- 
ment, and  salicylanalide  ointments  or  propionate 
caprylate  liquid.  A practical  method  which  I 
have  found  fairly  effective  is  the  use  of  ointment 
at  night,  shampoo  in  the  morning,  and  fungici- 
dal solution  or  one  of  the  other  ointments,  again 
following  shampoo.  This  can  be  carried  out  daily 
at  home. 

c.  Under  the  Wood’s  light  the  doctor  removes 
all  loose  fluorescent  hairs.  This  is  a very  im- 
portant part  of  the  treatment. 

d.  If  after  30  treatments  to  the  scalp  of  a 
proven  local  medicament,  there  should  be  noted 
a spread  to  other  areas  of  the  scalp,  a change 
should  be  made  to  another  medicament  which 
has  proven  to  be  of  therapeutic  value  in  at  least 
30  per  cent  of  a fairly  large  number  of  cases 
treated.  If  after  another  30  days’  trial  there  is  no 
progressive  improvement.  X-ray  epilation  should 
be  resorted  to. 

e.  Parents  must  be  given  written  and  verbal 
instructions  during  the  first  visit  and  reinstructed 
several  times  during  the  course  of  treatment  and 
observation. 

f.  A patient  is  considered  cured  only  when  4 
to  6 weekly  examinations  reveal  the  absence 
of  fluorescence. 

The  last  visit  should  include,  as  a final  check, 
cultures  and  direct  examinations  of  any  sus- 
pected hairs. 

Fungus  infection  of  the  nails.  The  common 
etiologic  agents  are  T.  gypseum  and  7’.  ruhrum. 
\ few  clinical  characteristics  must  be  borne  in 
mind,  which  are  as  follows: 

1 . The  toenails  are  more  often  involved  than 
the  fingernails. 


10 


F iingus  Infection s — Peck 


JANUARY,  1952 


2.  The  infection  begins  distally  or  at  the  lateral 
borders. 

3.  Whitish  patches  are  often  the  only  mani- 
festation of  a fungus  infection. 

4.  Subungual  keratosis  with  separation  of  the 
nail  plate  is  often  found. 

5.  Paronychia  is  rare. 

6.  The  disorder  is  rare  in  children. 

7.  When  there  is  inflammation  present  the 
prognosis  is  better. 

Locally  the  following  procedures  are  recom- 
mended in  the  treatment: 

The  nail  should  be  scraped  down  with  a file 
or  scalpel,  or  better  yet  by  a small  electric  burring 
machine.  It  is  advisable  that  the  physician  him- 
self should  do  the  burring.  (The  removed  parts 
of  the  nail  should  be  collected  on  paper  and 
burned.) 

After  thorough  scraping,  the  following  reme- 
dies are  recommended  for  application: 

Whitfield’s  ointment  with  1 per  cent  thymol 
is  rubbed  thoroughly  into  the  nail.  Instead  of 
this  ointment  So{)ronol  or  Desenex  ointment  may 
be  applied.  In  long-standing  cases  Anthralin  oint- 
ment, 0.25  per  cent,  or  5 per  cent  chrysarobin  in 
collodium  may  be  painted  on. 

A 10  to  20  per  cent  potassium  hydroxide  solu- 
tion may  be  applied  half  an  hour  before  applica- 
tion of  the  above-mentioned  remedies  in  order 
to  soften  the  nail. 

A 40  per  cent  salicylic  acid  plaster,  cut  to  cover 
the  nail  and  changed  daily,  is  recommended  by 
Royal  Montgomery. 

'I'he  old  medicament  must  be  scraped  away 
before  any  new  application  is  made. 

Complete  evulsion  of  nails  cannot  be  recom- 
mended, since  recurrences  almost  invariably  fol- 
low. 

Months  of  intensive  therapy  are  usually  neces- 
sary to  obtain  results.  But  the  patient  should  be 
made  to  realize  that  he  must  cooperate;  other- 
wise the  nails  will  be  the  source  of  relapses  of 
dermatophytosis  of  the  feet  and  hands. 

In  some  instances  X-ray  treatment  has  proven 
beneficial,  but  it  must  be  borne  in  mind  that  this 
])rocedure  does  not  kill  the  fungi.  It  should  be 


pointed  out  that  overtreatment,  especially  surgi- 
cal removal  of  the  nails,  will  lead  to  malforma- 
tions without  a cure  in  most  instances. 

The  discussion  of  the  treatment  of  fungus  in- 
fections has  been  limited  to  fungus  infections  of 
the  hands  and  feet,  the  scalp  and  the  nails,  since 
space  does  not  permit  a presentation  of  this  sort 
for  more  detailed  talks  of  the  various  fungus 
diseases. 

Summary 

There  is  reviewed  the  mechanism  responsible 
for  the  allergic  manifestations  accompanying 
fungus  diseases.  The  varied  clinical  manifesta- 
tions due  to  fungus  allergy  are  given  in  detail. 
Methods  for  the  diagnosis  of  both  fungus  dis- 
eases and  their  allergic  manifestations  are 
presented. 

The  relationship  between  previous  fungus  in- 
fections and  reactions  following  the  administra- 
tion of  antibiotics,  especially  penicillin,  are 
discussed  in  light  of  recent  findings. 

The  therapy  of  fungus  infections,  particularly 
tinea  capitis,  is  given  in  some  detail. 

BIBLIOGRAPHY 

1.  Peck:,  S.  M.,  Botvinick,  I.,  .and  Schw.artz,  L.:  .\rch. 

Dermal.  & Syph.,  194-1,  50,  170. 

2.  Wf.idm.an,  F.  I).,  Emmons,  C.  W.,  Hopkins,  J.  G.,  .and 

Lewis,  G.  M.:  J.A.M.A.,  1945,  128,  805. 

3.  Osborne,  E.  I).,  .and  Hitchcock,  B.  S.:  Ibid.,  1931, 

97,  453. 

4.  ScHW.ARTZ,  L.,  .AND  OTHERS:  Control  of  Ringworm  of  the 

Scalp  among  School  Children.  Pub.  Health  Bull.  No. 
294,  1944-45. 

5.  J.AD.ASSOHN,  \V.,  .ANT)  Peck,  S.  M.  : .^rch.  Dermal,  u. 

Syph.,  1929,  158,  16. 

6.  Peck,  S.  M.:  .\rch.  Dermal.  & Syjrh.,  1930,  22,  40. 

7.  Peck,  S.  M.:  .\nn.  New  5’ork  .\cad.  Sc.,  1950,  50,  1362. 

8.  Bloch,  B.,  L.abruchere,  .V.,  .and  Sch.aaf,  E. : .\rch. 

Dermal,  u.  Syph.,  1925,  148,  413. 

9.  Lewis,  G.  M.,  Hopper,  M.  E.,  .and  Reiss,  E.  : 

1946,  132,  62. 

10.  Peck,  S.  M.,  Glick,  .\.,  .and  Weissb.ard,  E.:  .\rch. 

Dermal.  & Syph.  1941,  44,  816. 

11.  Peck,  S.  M.,  .and  Hewitt,  W.  L.:  Pub.  Health  Bull,  1945, 

60,  148. 

12.  Peck,  S.  M.,  Sieg.al,  S.,  Glick,  .\.,  .and  Kurtin,  .\.; 

1948,  138,  631. 

13.  Welch,  IL,  .and  Rostf.nberg,  .V.,Jr.:  Ibid.,  1944,  126,  10. 

14.  Rostenberg,  .\.,  Jr.,  .and  Welch,  IL:  .\m.  J.  M.  Sc., 

1945,  210,  158. 


APPLICATION  OF  ELECTROPHORESIS  TO  MEDICAL 
PROBLEMS 


^ N RECENT  years  the  boundaries 
between  the  various  sciences  have  overlapped 
considerably  and  it  is  no  longer  surprising  that 
physical-chemical  methods  have  been  utilized 
to  investigate  clinical  problems.  There  has  been 
a wide  and  varied  application  of  electrophoresis 
to  them  since  various  types  of  apparatus  based  on 
the  ideas  of  Tiselius'  and  Svensson-  have  become 
available.  This  paper  is  not  an  attempt  to  cover 
the  field  completely  but  will  be  limited  to  those 
aspects  of  the  subject  bearing  directly  on  clinical 
problems.  For  a complete  review  see  the  article 
by  Stern  and  Reiner.^ 

Electrophoresis  may  be  defined  as  the  migra- 
tion of  charged  particles  in  electrical  fields.  In 
the  moving-boundary  method  the  progress  of 
the  boundaries  formed  between  colloidal  (such 
as  protein)  and  buffer  solutions  may  be  followed 
by  optical  methods.  This  is  possible  because  of 
the  differences  in  refractive  index  between  the 
buffer  and  the  protein  fractions  at  the  boundaries 
(“schlieren”).  Tiselius^  in  1937  examined  horse 
serum  in  his  apparatus  and  observed  5 bounda- 
ries of  different  electrophoretic  mobility;  it  was  for 
this  work  that  he  received  the  Nobel  prize.  The 
fastest  boundary  was  identified  as  albumin;  the 
3 following  were  recognized  as  3 different  globulin 
components,  alpha,  beta  and  gamma  globulin  in 
decreasing  order  of  mobility.  Shortly  afterward 
the  stationary  delta  boundary  observed  in  the 
ascending  limb  of  the  apparatus  and  the  cor- 
responding epsilon  boundary  in  the  descending 
limb  were  recognized  as  boundary  anomalies, 
largely  because  of  the  transport  of  buffer  ions  by 
the  proteins  during  electroj)horesis  but  also 
f)artly  because  of  a superimposed  general  j)rotein 
gradient  rather  than  an  additional  individual 
protein  component. 


MIRIAM  REINER,  M.S. 

Director  of  Chemistry  Department,  Division  of  Laboratories, 
Gallinger  Municipal  Hospital,  Washington 


The  number  of  boundaries  observed  in  electro- 
phoresis experiments  on  serum  or  plasma  de- 
pends upon  the  type  of  buffer  employed  and  the 
species  under  study.  Longsworth^  has  shown  that 
the  use  of  a barbital  buffer  at  pH  8.6  and  an 
ionic  strength  of  0.1  leads  to  the  resolution  of 
human  plasma  into  6 well-defined  components, 
namely,  albumin,  alphai,  alphas,  beta  and  gamma 
globulins  in  addition  to  fibrinogen.  The  ascend- 
ing and  descending  boundary  patterns  are  not 
identical.  In  general,  the  rising  or  ascending 
boundary  is  better  defined  than  the  falling  or 
descending  one;  the  l)eta  peak  in  the  descending 
limb  shows  a peculiar  spike  probably  due  to  a 
reflection  phenomenon.  Figure  1 presents  a char- 
acteristic normal  serum  protein  pattern  (ascend- 
ing boundary). 


• > 


Fig.  1.  Rei)resentative  electrojjhoresis  diagram  of  normal 
human  serum,  recorded  with  slit  diaphragm.  Serum  diluted 
with  2 volumes  of  diethylharhiturate  buffer,  pH  8.6,  ionic 
strength,  0.1.  Duration  of  exjieriment  8,580  seconds  al  1.9°('., 
and  a j)otential  gradient  of  4.5  v./cm.  I’rotein  concentration, 
2.35  per  cent.  Fxjilanation  of  symbols:  A,  serum  albumin; 
ai,  alphai-protein;  <*2,  alpha2-globulin;  fi,  beta-globulin;  7, 
gamma-globulin;  5,  stationary  anomalous  boundary,  due  lo 
fjrotein-buffer  salt  gradient. 


11 


12 


Electrophoresis — Reiner 


JANUARY,  1952 


Under  patho-physiologic  conditions  there  may 
be  an  increase  in  the  area  under  any  one  of  the 
protein  peaks.  However,  since  Cohn  and  his 
associates®  have  found  at  least  33  components  of 
human  plasma,  the  increase  may  be  due  to  an 
anomalous  or  specific  protein  of  similar  mobility 
such  as  immune  bodies,  Bence-Jones,  or  lipo- 
protein complexes  rather  than  an  increase  in  the 
amount  of  one  of  the  normal  components.  So 
far  about  4 betai,  3 alphai,  several  alphas,  and 
at  least  4 different  gamma  globulins  have  been 
separated.  In  general  the  fractions  are  associated 
with  other  molecules  as  follows:  Albumin  may 
combine  with  bilirubin,  bile  salts,  sulfonamides, 
salicylates  and  many  other  drugs,  dyes,  mercury, 
arsenic  and  fatty  acids. The  alphai-globulin 
fraction  may  contain  acid  glycoprotein,  biliru- 
bin-globulin and  lipoproteins  (steroids  and  carot- 
enoids). The  alpha.)  fraction  contains  the  glyco- 
proteins and  mucoproteins  which  combine  with 
carbohydrates.  The  betai  fraction  accounts  for 
about  75  per  cent  of  all  the  lipids  in  the  plasma 
including  cholesterol,  phosphatids,  carotenoids, 
vitamin  A and  estrogens;  there  is  also  a metal- 
combining iron  and  copper  protein  betai  frac- 
tion. Some  antigens  are  associated  with  the  beta^- 
globulin  fraction.  The  gamma-globulin  fraction 
may  contain  antigens,  antitoxins,  antibodies,  and 
allergic  reagins.  There  are  many  other  plasma 
protein  fractions  that  take  part  in  the  blood 
clotting  and  hemorrhagic  reactions  which  are 
separable  by  other  means  than  electrophoresis. 
The  separation  of  pure  fractions  is  extremely 
complex,  since  each  fraction  may  be  considered 
as  an  envelope  enclosing  many  substances  in  addi- 
tion to  the  particular  “normal”  protein  fraction. 

The  figures  obtained  for  albumin  and  “globu- 
lin” by  the  Howe  (sodium  sulj)hate)  method  must 
be  somewhat  revised,  since  it  has  been  shown  that 
this  method  does  not  achieve  a clear-cut  separa- 
tion between  the  albumin  and  globulins  (A  'G 
ratio).  The  so-called  pseudoglobulin  and  euglobu- 
lin  preparations  which  may  be  obtained  by  salt- 
ing-out and  dialysis  methods  represent  mixtures; 
pseudoglobulin  was  found  by  Tiselius  to  contain 


85  per  cent  alpha-globulin  and  15  per  cent 
gamma-globulin,  while  euglobulin  contains  more 
beta  and  gamma  but  less  alpha-globulin.  Dis- 
crepancies will  be  found  between  the  conven- 
tional “salting-out”  and  the  electrophoretic 
method  of  serum  protein  separation.  This  is  due 
to  the  incomplete  precipitation  of  the  globulins 
whereby  some  alpha  globulin  is  usually  left  with 
the  albumin  fraction.  This  is  more  pronounced  irr 
some  diseases,  particularly  those  involving  the 
liver  and  kidney,  in  which  the  proteins  are 
changed  qualitatively  as  well  as  quantitatively. 

The  following  figures  were  obtained  by  sta- 
tistical analysis  of  the  experimental  data*  for  a 
group  of  60  “family”  blood  donors  representing 
a cross-section  of  a mixed,  adult,  urbane  popu- 
lation. The  total  protein  was  7.22  ± 0.48  grams 
per  100  ml.  of  serum.  The  following  figures  are 
in  terms  of  relative  concentration:  albumin,  56.8 
zb  3.0  per  cent;  alphai-globulin,  7.2  zb  1.2  per 
cent;  alpha2-globulin,  8.7  zb  1.5  per  cent;  beta- 
globulin,  12.8  zb  2.3  per  cent,  and  gamma-globu- 
lin, 14.4  zb  2.4  per  cent;  the  albumin-globulin 
ratio  was  1.33  zb  0.18  per  cent. 

The  electrophoretic  diagram  of  blood  serum 
and  plasma  reflects  the  physiologic  state  of  the 
individual  as  a whole  rather  than  representing 
a specific  pattern  corresponding  to  a specific 
disease  with  the  exception  of  IMilroy’s  disease, 
certain  types  of  multiple  myeloma,  nephrosis, 
and  disseminated  lupus  erythematosus. 

Milroy's  disease  or  hypogammaglobulinemia. 
This  is  a rare  condition  in  which  the  patient  has 
a low  total  protein  with  almost  complete  ab- 
sence of  gamma-globulin  and  with  edema  as  the 
only  symptom.  Schick  and  Greenbaum®  have 
followed  a patient  since  birth  for  20  years. 
Surprisingly  she  showed  a complete  lack  of  child- 
hood infectious  diseases.  The  diagnosis  was  not 
made  until  she  was  12  years  old,  and  an  electro- 
phoretic pattern  of  her  serum  showed  practically 
no  gamma-globulin.  She  has  been  followed  for  8 
years  since  then,  but  there  is  only  a temporary 
change  in  the  protein  pattern  when  she  is  given 
albumin,  gamma-globulin,  antiserum,  or  ACTH. 


VOL.  XXI,  NO.  1 


Medical  Annals  of  the  District  of  Columbia 


13 


Her  total  serum  protein  has  varied  between  4 
and  5 Gm.  in  100  ml.  of  serum,  while  her  gamma- 
globulin has  never  risen  much  higher  than  0.3 
Gm. 

Nephrosis.  This  disease  shows  a highly  atypical 
serum  pattern  with  an  extremely  low  albumin 
and  gamma-globulin  content  and  an  electro- 
phoretic component  migrating  in  the  alpha  and 
beta  globulin  regions  with  a concentration  com- 
parable to  that  of  albumin  in  normal  serum 
(figure  2).  The  urine  of  such  patients  yields  an 
electrophoretic  pattern  closely  resembling  that  of 
normal  serum  and  thus  representing  a striking 
contrast  to  the  serum  of  the  same  individual. 


norhal  huhan  seruh 




AMYLOIDOSIS 

SUBACUTE  BACTERIAL 

ENDOCARDITIS 

/\ ^ 

■ 

BRUCELLOSIS 

LIVER  CIRRHOSIS 

XALA-AZAR 

NEPHROSIS 

Fig.  2.  Serum  jirotein  [latlerns  in  various  ty[)es  of  disease. 
Ascending  boundaries,  barbiturate  buffer,  pH  8.6. 


This  indicates  that  the  excretion  of  urinary  pro- 
tein by  the  kidney  is  a highly  selective  process 
rather  than  a simple  filtration. 

Lther  extraction  of  a nephrotic  serum  causes 
a drastic  reduction  of  the  /3-component  peak 


which  suggests  that  the  increase  in  that  region 
is  due  to  a lipoprotein.  It  is  conceivable  that  the 
very  low  albumin  concentration  may  be  due  to 
an  excessive  loss  of  this  protein  through  the 
kidney. 

Multiple  myeloma.  This  is  one  of  the  most 
challenging  diseases  for  the  protein  chemist  and 


MYELOMA  SERUM  "NORMAL  TYPE"  MYELOMA  SERUM  "a"  TYPE 


MYELOMA  SERUM  "BETA  TYPE"  MYELOMA  SERUM  "GAMMA  TYPE" 
Fig.  3.  Serum  jjrolein  jiat terns  from  patients  with  multijile 


myeloma. 

also  one  of  the  most  baffling,  since  4 different 
patterns  may  be  observed  in  different  patients, 
pseudonormal  as  well  as  those  patterns  contain- 
ing an  abnormal  protein  fraction  in  the  alpha, 
beta  or  gamma  regions,  and  which  may  or  may 
not  correspond  to  the  Bence-Jones  protein  ex- 
creted in  the  urine  of  some  of  these  patients. 
There  seems  to  be  no  correlation  between  the 
clinical  state  of  the  paient,  the  type  of  electro- 
phoretic pattern,  the  excretion  of  Bence-Jones 
protein  in  the  urine,  inclusion  bodies,  sedimenta- 
tion rate,  nor  any  specific  changes  in  the  blood 
chemistry.'"  (See  figure  3 for  various  types  of 
protein  patterns  in  multi{)le  myeloma.)  The 
anomalous  protein  in  the  beta  region  shows  con- 
siderable variation  in  mobility  outside  of  the 
limits  of  normal  beta-globulin.  It  has  been 


14 


Electrophoresis — Reiner 


JANUARY,  1952 


suggested"  that  this  material  is  identical  with 
Bence-Jones  protein  on  the  basis  of  model  electro- 
phoresis experiments  as  well  as  in  the  ultracentri- 
fuge. Other  investigators^-  found  that  the  mate- 
rial with  gamma  molrility  is  neither  identical 
with  Bence-Jones  protein  nor  with  mixed  gamma- 
globulin in  spite  of  similar  mobility  and  sedi- 
mentation constants.  It  differs  from  the  normal 
gamma-globulin  by  its  high  electrophoretic 
homogeneity  and  amino  acid  composition  as  de- 
termined by  paper  chromatography. 

In  a series  of  91  cases  studiecff”  approximately 
22  per  cent  were  of  the  pseudonormal  type, 
6.6  per  cent  of  the  alpha-globulin  type,  15.4  per 
cent  of  the  beta-globulin  type,  and  54.9  per  cent 
of  the  gamma  type.  The  last  has  also  been  found 
to  be  the  most  frequently  occurring  type  by  other 
investigators. 

Disseminated  lupus  erythematosus.  Although 
the  total  protein  content  of  the  sera  is  generally 
within  normal  limits  in  this  condition,  the  al- 
bumin concentration  is  decreased;  the  alpha2  and 
gamma-globulin  are  increased,  while  the  alphai 
and  beta-globulin  fractions  remain  in  the  nor- 
mal range. This  causes  a reversal  of  the  A G 
ratio. 

The  gamma-globulin  may  be  increased  by  50 
per  cent  of  the  total  protein  content.  Usually 
hypergammaglobulinemia  is  encountered  either 
in  infectious  diseases  or  in  some  involvement  of 
the  liver,  e.g.,  cirrhosis.  As  the  condition  of  the 
patient  improves  temporarily  either  under  treat- 
ment or  during  a spontaneous  remission  of  the 
disease  the  amount  of  gamma-globulin  will  de- 
crease and  the  all)umin  will  increase.  While  the 
alphai-globulin  concentration  is  normal,  the 
alpha2-globulin  content  is  increased  to  twice  the 
normal  amount.  This  fraction  during  remission 
or  after  treatment  very  rarely  returns  to  normal 
values. 

The  sera  of  5 patients  were  studied  before 
therapy  with  cortisone  and  adrenocorticotropin 
(ACTH).  After  a clinical  remission  had  been 
produced  by  these  agents  it  was  found  that  the 
albumin  and  gamma-globulin  components  tended 
to  return  toward  normal  levels  while  the  alphai- 


globulin  fraction  remained  unchanged  (figure 

■i)- 

There  are  many  diseases  which  do  not  show 
specific  patterns  but  fall  into  general  types.  Thus, 
tuberculosis  and  pneumonia  as  well  as  other 
febrile  and  tissue-wasting  diseases  show  an  in- 
crease in  the  alpha-globulin  fraction.  The  albu- 
min is  reduced  to  a variable  extent,  and  the 
fibrinogen  and  gamma-globulin  are  found  to  be 
increased  in  active  cases  of  tuberculosis. 

Hodgkin's  disease.  The  electrophoretic  serum 
protein  diagrams  were  nonspecific  but  seemed  to 
be  correlated  with  the  clinical  state  of  the  pa- 
tient and  thus  were  of  prognostic  value."  From 
pseudonormal  patterns  at  the  onset  of  the  disease 
the  patterns  changed  at  intermediate  stages  to 
show  greatly  elevated  gamma-globulin  levels. 
In  the  terminal  stage  there  was  observed  a rela- 
tive decrease  in  the  albumin,  an  inverted  A/  G 
ratio,  and  greatly  enlarged  alphar  and  alpha2- 
globulin  components,  which  in  some  instances 
become  the  major  protein  fraction  in  the  serum. 

Infectious  diseases  in  which  antibodies  are 
formed  in  response  to  specific  antigens  of  bacterial 
or  viral  origin.  The  gamma-globulins  are  in- 
creased, although  the  large  increase  in  this 
fraction  can  hardly  be  accounted  for  by  the  anti- 
bodies alone,  since  the  actual  amount  of  anti- 
bodies present  has  been  found  to  be  small.  (See 
figure  2 for  protein  patterns  in  subacute  bacterial 
endocarditis  and  brucellosis.) 

Syphilitic  sera  showed  an  elevated  gamma- 
globulin and  a decreased  albumin  level,  but  the 
changes  cannot  be  correlated  with  serologic  ac- 
tivity. Kala-azar  sera  have  not  only  a high  total 
protein  content  but  also  a tremendous  increase 
in  the  gamma-globulin  fraction  (figure  2). 

Liver  disease.  Since  the  liver  seems  directly 
involved  in  the  synthesis  of  proteins  and  there 
is  usually  a change  in  the  A G ratio  in  practically 
all  types  of  liver  diseases,  it  has  been  of  particular 
interest  to  study  them  electrophoretically  (fig- 
ure 2).  A constant  finding  has  been  a decrease 
in  serum  albumin  and  an  increase  in  some  of 
the  globulin  fractions,  most  often  the  gamma- 
globulin and  less  frequently  the  beta-globulin 


VOL.  XXI,  NO.  1 


Medical  Annals  of  the  District  of  Columbia 


15 


fraction.  Usually  in  a serum  with  increased 
beta-globulin  the  thymol  turbidity  test  will  be  in- 
creased and  a positive  cephalin  flocculation  test 
will  accompany  a high  gamma-globulin.  The 


(Figure  4-a) 


total  protein  content  may  be  normal  or  increased 
with  an  inverted  A G ratio.  The  correlation  be- 
tween the  chemical  and  electrojihoretic  data  is 
not  very  close  because  of  the  alteration  of  the 
protein  constituents  during  the  disease.  As  the 
patient  recovers  the  serum  protein  patterns  re- 
turn to  normal.^® 

The  beta-globulins,  especially  the  beta-lipo- 
protein fraction,  have  attracted  much  attention 
during  the  last  year  since  Gofman  and  his 
associates'®  have  linked  the  presence  of  an  ultra- 
centrifugally  separated  macromolecular  lipopro- 
tein component  to  the  incidence  of  atherosclero- 
sis. This  has  given  a tremendous  impetus  to 
lipoprotein  studies  by  many  other  technics. 

.Another  recent  development  is  the  study  of 
sickle-cell  anemia  by  Pauling  and  his  group'^  in 
California,  who  found  that  the  hemoglobin  from 
sickle-cells  has  a different  electrophoretic  mobil- 
ity than  normal  hemoglobin,  hence  it  has  been 
called  a “molecular  disease.”  The  “anemic” 
hemoglobin  molecule  carries  more  positive 
charges  than  the  normal  hemoglobin  molecule, 
and  Pauling  believes  that  the  molecules  are  able 
to  form  a bond  with  other  hemoglobin  molecules, 
which  leads  to  a distortion  of  the  red  blood  cells. 
'I'he  normal  red  blood  cell  proteins  had  been  stud- 
ied previously'*  and  were  found  to  have  3 com- 
ponents of  different  electrophoretic  mobility,  one 
with  a mobility  of  hemoglobin,  one  (a-compo- 
nent)  slightly  faster,  and  one  (/3-component)  some- 
what slower.  These  studies  of  hemoglobin  and 
red  blood  cell  proteins  offer  a new  approach  to 
the  study  of  hemorrhagic  diseases."* 


Radioactive 
iodine  and 
other  tracer 
substances 
have  been 
used  success- 
fully in  com- 
bination with 


(Figure  4-b) 

Fig.  4.  .Studies  of  serum  proteins  from  patients  with  dis-  (4-1))  hdectrophoretic  diagrams  of  the  serum  proteins  of  1 

seminated  lupus  erythematosus.  (4-a)  Kej)resentative  electro-  patient  with  disseminated  lupus  erythematosus  before  (.\)  and 

phorelic  patterns  of  normal  serum  (.\),  and  of  2 sera  from  after  therapy  with  cortisone  and  .\('TH  (It), 
patients  with  disseminated  lujius  erythematosus  (B,  C). 


16 


Electrophoresis — Reiner 


JANUARY,  1952 


electrophoresis  technics.'-*'  As  an  example,  after 
the  administration  of  1 131  the  blood  serum  of  pa- 
tients was  fractionated  in  the  electrophoresis 
apparatus  and  the  various  fractions  were  then 
tested  for  their  specific  radioactivity.  It  was 
shown  that  the  albumin  and  gamma-globulin 
fractions  are  practically  free  of  organically  bound 
iodine,  the  largest  concentration  being  in  the 
alpha2  and  beta-globulin  regions  of  the  electro- 
phoresis cell. 

Proteins,  particularly  albumin,  have  been 
tagged  with  Im,  and  the  rate  of  disappearance 
and  turnover  have  been  studied  in  man  and  in 
the  rabbit.^* 

The  lymph,  serous  and  pleural  efYusions,  joint, 
eye,  seminal  and  cerebrospinal  fluids,  pancreatic 
juice,  milk  proteins,  and  tissue  extracts,  from 
both  normal  and  pathologic  tissues  of  man  and 
of  a variety  of  animals,  have  been  studied.  Tu- 
berculin, bacterial  preparations,  snake  venoms, 
hormones  and  gland  extracts,  and  enzyme  prep- 
arations as  well  as  nucleoproteins  have  been  char- 
acterized by  electrophoretic  examination.  Cohn 
and  his  group  at  Harvard  have  employed  electro- 
phoresis to  control  the  chemical  separation  of  the 
various  plasma  protein  fractions,  such  as  albu- 
min, globulins,  fibrin,  hemoglobin,  lipoproteins, 
thrombin,  and  isoagglutinins. 

The  first  investigators  in  the  medical  field  were 
a{)parently  anxious  to  find  a specific  protein  pat- 
tern for  each  disease.  That  this  has  not  mate- 
rialized except  in  a few  instances  is  not  surprising, 
since  there  exists  such  a multiplicity  of  symptoms 
of  tissue  and  organ  involvement  in  many  syn- 
dromes. Electrophoresis  probably  will  be  found 
more  useful  in  following  the  course  of  progressive 
protein  changes  during  a disease  rather  than  in 
its  diagnosis.  It  should  be  looked  upon  primarily 
as  an  analytical  tool  of  established  value  in 
quantitative  studies  of  complex  mixtures  of  col- 
loids of  biologic  interest,  particularly  proteins. 

SUMr.I.ARY 

The  application  of  electrophoresis  to  medicine 
has  been  discussed  and  its  usefulness  has  been 


demonstrated  in  medical  and  biological  fields.  It 
is  the  most  dependable  means  of  analyzing  the 
protein  content  of  body  fluids,  which  serve  as  an 
index  of  the  physiologic  state  of  the  patient. 
Even  though  there  may  not  be  a specific  pattern 
for  each  separate  disease,  significant  alterations 
of  the  protein  spectrum  may  be  followed  during 
the  course  of  the  disease,  and  thus  it  may  be  of 
prognostic  if  not  diagnostic  value. 

In  a few  instances  such  as  Milroy’s  disease, 
nephrosis,  liver  disease,  disseminated  lupus  ery- 
thematosus and  certain  types  of  multiple  mye- 
loma, the  protein  pattern  is  distinctive  and  may 
be  of  direct  diagnostic  assistance. 

The  application  of  this  physico-chemical  tech- 
nic has  led  to  fresh  approaches  in  problems  of 
physiology  and  medicine  which  may  change  our 
former  concepts  and  ultimately  lead  to  a better  ^ 
understanding  of  normal  and  pathologic  proc- 
esses. 

BIBLIOGRAPHY 

1.  Tiselius,  Tr.  Faraday  Soc.,  1937,  33,  524. 

2.  SvENSSON,  H.;  .\rk.  Kemi  miner.  Geol..  1946,  22.\  (No.  10). 

3.  Stern,  K.  G.,  .\nd  Reiner,  M.:  Yale  J.  Biol.  & Med., 

1946,  19,  67. 

4.  Tiselius,  .A.;  Biochem.  J.,  1937,  31,  1464. 

5.  Longswortii,  L.  G.:  Chem.  Rev.,  1942,  30,  323. 

6.  Gohn,  E.  j.,  .and  others:  Preparation  and  [iroperlies  cf 

serum  and  plasma  proteins,  from  collection  of  reprints 
of  J.  .\m.  Chem.  Soc.,  1946-1949. 

7.  Oncley,  j.  L.,  in  Plasma  Proteins,  edited  by  Youm.ans,  J. 

B.  Springfield,  111:  Thomas,  1950,  vol.  2. 

8.  Reiner,  M.,  Fenichel,  R.  L.,  .and  Stern,  K.  G.:  .\cta 

Haemat.,  1950,  3,  202. 

9.  Schick,  B.,  and  Greenbaum,  J.  \Y.:  J.  Pediat.,  1945,  27, 

241. 

10.  Reiner,  M.,  .and  Stern,  K G.:  Electrophoretic  studies  on 

protein  distribution  in  serum  of  multifile  myeloma 
patients,  to  be  published. 

11.  Moore,  D.  H.,  K.ab.at,  E.  .and  Gutman,  A.  B.:  J. 

Clin.  Investigation,  1943,  22,  67. 

12.  Stern,  K.  G.,  and  Laszlo,  D.:  Cancer  Res..  1950.  10,  242. 

13.  Reiner,  AL:  Proc.  Soc.  Exjier.  Biol.  & Aled.,  1950,  74, 

529. 

14.  Rotting,  Suchoff,  I).,  and  Stern,  K.  G.:  J.  Lab.  & 

Clin.  Med.,  1948,  33,  624. 

15.  Rafsky,  H.  .a.,  a.nu  others:  Gastroenterology,  19.S0,  14. 

29. 

16.  Gof-MAN,  j.  \\'.,  AND  others:  Science.  1950.  Ill,  166. 

(Conlinued  on  pa^e  60) 


CAUSES  AND  SIGNIFICANCE  OF  HOARSENESS 

PAUL  H.  HOLINGER,  M.D. 

Professor  of  Laryngology  and  Broncho-Esophagology,  University 
of  Illinois  School  of  Medicine 


OARSENESS  may  be  defined  as 
a rough  discordant  quality  of  the 
voice.  It  is  so  common  an  affliction  that  most  of 
us  have  e.xperienced  it  frequently  and  therefore 
its  significance  is  often  overlooked.  One  thinks 
of  hoarseness  primarily  in  terms  of  the  common 
cold,  but  he  must  also  consider  the  triumvirate 
which  frequently  affects  the  laryn.x:  carcinoma 
lying  in  the  anterior  commissure,  tuberculosis  in 
the  posterior  commissure,  and  syphilis,  the  great 
imitator,  present  anywhere  throughout  the 
larynx. 

Hoarseness  is  usually  a manifestation  of  a 
local  lesion.  In  normal  phonation  a column  of 
air  rises  from  the  trachea  through  the  larynx; 
here  the  cord  edges  break  it  into  small  puffs  of 
air  which  are  blown  into  the  oral  pharynx  where 
articulation  takes  place.  A clear  voice  depends 
upon  smooth  cords  of  equal  tension  and  texture, 
since  these  determine  the  accurate  formation  of 
the  individual  “puffs.”  Changes  in  tension,  tex- 
ture, or  regularity  of  the  cord  edges  produce 
hoarseness.  Inflammatory  lesions  cause  a damp- 
ening of  the  vibrations  of  the  cord  edges.  Neuro- 
logic lesions  cause  changes  in  tension  of  the  cord 
edges.  Mechanical  lesions,  such  as  tumors  or 
foreign  bodies  lying  between  the  cords,  prevent 
accurate  approximation  and  cause  an  air  loss 
around  the  lesion  which  accounts  for  hoarseness. 

.Although  a local  lesion  may  be  responsible  for 
the  change  in  the  character  of  the  voice,  systemic 
disease  not  infrequently  influences  the  condition 
of  the  cords.  Nephritis,  for  example,  can  cause 
laryngeal  edema;  diphtheria  is  a systemic  disease, 
although  the  acute  inflammation  of  the  larynx 
together  with  the  membrane  are  local  manifesta- 

* .tdflress  delivered  before  the  Twenty-second  .'\nnual 
Scientific  .Assembly  of  the  Medical  Society  of  the  District  of 
Columbia,  October  2,  19.S1. 


tions.  Mediastinal  tumors  may  cause  changes 
through  vascular  engorgement  and  paralysis  of  a 
vocal  cord.  Neurogenic  disease  such  as  amyo- 
trophic lateral  sclerosis  may  influence  the  char- 
acter of  the  voice  through  paralyses  or  pareses. 
Tuberculosis  may  cause  voice  changes  due  to 
indirect  action  of  the  systemic  disease  on  the 
larynx  or  through  local  changes. 

The  various  causes  of  hoarseness  may  be  dis- 
cussed as  they  affect  different  age  groups. 
Changes  in  the  cry,  or  the  absence  of  the  cry, 
in  the  newborn  infant  makes  one  suspect  the 
presence  of  a congenital  anomaly.  Such  lesions 
as  congenital  laryngeal  webs,  cysts,  or  paralyses 
must  be  considered.  The  common  congenital 
laryngeal  stridor  with  a soft  flaccid  larynx  on 
occasion  may  be  associated  with  marked  hoarse- 
ness. Paralyses  of  the  larynx  in  newborns  may 
be  central  or  peripheral  in  origin,  due  to  brain- 
stem lesions  or  to  various  cardiovascular  anoma- 
lies which  involve  the  left  recurrent  laryngeal 
nerve.  Birth  injuries  due  to  a central  hematoma 
may  be  responsible  for  vocal  cord  paralysis  in 
the  newborn  infant.  In  the  newborn  group  one 
also  has  to  consider  the  possibility  of  catheteri- 
zation edema  of  the  larynx  which  may  follow 
repeated  attempts  to  catheterize  the  larynx  for 
the  aspiration  of  secretions  from  the  tracheo- 
bronchial tree.  Such  rc[)eated  attempts  are  dan- 
gerous, since  the  edema  produced  may  be  suffi- 
cient to  cause  acute  respiratory  obstruction  in 
addition  to  hoarseness. 

In  children  the  commonest  cause  of  hoarseness 
is  laryngitis  associated  with  upper  respiratory 
infections.  The  history  is  usually  sufficient  to 
establish  the  diagnosis;  not  infrefjuently  the  in- 
fection continues  throughout  the  respiratory 
tract  to  give  the  typical  picture  of  acute  or 
chronic  laryngotracheobronchitis.  Diphtheria 


17 


Hoarseness 


Holinger 


JANUARY,  1952 


1<S 

must  always  be  considered  in  children  who  have 
an  acute  respiratory  infection  associated  at  the 
onset  with  hoarseness. 

Chronic  laryngitis  may  have  as  its  basis  sinusi- 
tis or  bronchiectasis  with  the  entire  respiratory 
tract  subject  to  the  changes  of  chronic  inflam- 
mation. d'he  commonest  cause  of  chronic  hoarse- 
ness in  children  is  screamer’s  nodes,  the  small 
nodules  on  the  edges  of  the  vocal  cords  at  the 
junction  between  the  anterior  one  third  and 
posterior  two  thirds  of  the  cords  which  develop 
as  a result  of  vocal  abuse.  These  may  be  of  such 
long  standing  that  the  family  becomes  accus- 
tomed to  the  character  of  the  child’s  voice,  and 
only  during  episodes  of  acute  infection  does  the 
hoarseness  increase  in  severity  to  cause  the  fam- 
ily to  seek  advice.  One  is  at  a loss  to  determine 
how  to  treat  a child  with  screamer’s  nodes, 
since  in  his  active  play  he  must  use  and  abuse 
his  voice  without  constant  parental  discipline. 
If  the  nodules  are  large  they  may  be  removed 
under  direct  laryngoscopy;  if  they  are  small, 
voice  training  may  improve  the  ciuality  of  the 
voice,  but  this  is  not  always  possible  in  a grow- 
ing, healthy,  active  child.  Surgical  removal  of  the 
nodules  will  result  in  only  temporary  improve- 
ment if  voice  correction  therapy  is  not  instituted, 
and  the  nodules  will  recur  when  the  child  returns 
to  his  previous  habits  of  play  and  vocal  activity. 
These  nodes  tend  to  disappear  spontaneously 
during  puberty,  since  the  laryn.x  grows  rapidly 
and  stress  is  placed  on  other  parts  of  it  than 
those  affected  before  this  rapid  growth.  I'hen, 
too,  the  child  is  more  mature  and  somewhat  more 
guarded  in  the  use  of  his  voice  unless  he  engages 
in  such  activity  as  cheerleading. 

Fa])illoma  must  be  mentioned  as  a fairly  fre- 
quent cause  of  hoarseness  in  children.  Such 
hoarseness  is  slowly  progressive  and  begins  with 
a cough  and  slight  hoarseness  only  to  increase 
and  then  gradually  to  be  associated  with  respir- 
atory ditflculty.  The  management  of  such  chil- 
dren consists  of  endosco{)ic  removal  of  papilloma 
at  frecjuent  intervals  with  or  without  a tracheot- 
omy, depending  upon  how  much  papilloma  is 
present.  X-ray  therapy  of  papilloma  of  the  larynx 


in  children  is  to  be  strictly  avoided  since  it  re- 
sults in  destroying  the  growth  properties  of  the 
laryngeal  cartilages  and  therefore  in  chronic  la- 
ryngeal stenosis.  Aureomycin  seems  to  decrease 
the  frequency  of  recurrence  in  some  of  the 
children. 

In  the  adult  carcinoma  of  the  larynx  is  the 
first  consideration  in  patients  who  are  hoarse, 
and  every  diagnostic  means  has  been  used  to 
eliminate  this  lesion  from  the  many  causes  to  be 
considered.  Of  the  inflammatory  diseases  causing 
hoarseness  in  adults,  acute  laryngitis  of  bacterial 
origin  as  well  as  acute  laryngitis  of  traumatic 
origin  due  to  vocal  abuse  or  excessive  smoking 
must  be  considered  as  most  common.  Acute 
laryngitis  of  an  inflammatory  character  second- 
ary to  a common  cold  is  as  frequent  in  adults  as 
it  is  in  children.  Secondary  laryngitis  or  chronic 
laryngitis  may  have  as  its  basis  sinus  infection, 
bronchopulmonary  disease  or  postnasal  suppura- 
tion. Chronic  laryngitis  due  to  vocal  abuse  seen 
in  hucksters,  preachers  and  salesmen  is  generally 
uniform  in  character  and  as  such  forms  a distinct 
clinical  entity.  It  consists  of  an  ulceration  and 
later  a perichondritis  of  the  vocal  processes  of  the 
arytenoids.  Finally,  a granuloma  develoi)s  on  the 
I)honating  edge  of  the  arytenoid  and  the  opposite 
cord  begins  to  show  similar  signs  of  irritation 
and  develops  a deep  ulcer  at  the  point  of  contact 
with  the  granuloma  on  the  original  side.  The 
management  is  difficult  because  it  necessitates 
strict  voice  rest  for  a considerable  period  of  time. 
However,  these  patients  are  usually  reluctant  to 
follow  this  type  of  regime  since  their  livelihood 
de]:)ends  upon  vocal  function.  Voice  correction 
therapy  is  essential  for  the  ultimate  disappear- 
ance of  the  lesion.  Contact  ulcers  may  develop 
in  patients  who  continue  talking  in  spite  of  an 
acute  respiratory  infection;  the  ulcer  develops 
because  of  the  action  of  the  arytenoids  against 
each  other  in  the  attempt  to  overcome  the  damp- 
ening of  the  vibrations  caused  by  the  inflamma- 
tory changes  of  the  cords.  Thus,  it  is  important 
for  all  patients  who  develop  laryngitis  to  rest 
the  voice  by  eliminating  all  unnecessary  talking. 

Another  tvpe  of  lesion  whi('h  may  be  con- 


VOL.  XXI,  NO.  1 


Medical  Annals  of  the  District  of  Columbia 


19 


sidered  due  to  voice  trauma  is  that  of  the  singer 
who  abuses  his  voice  and  develops  nodules  at  the 
junction  between  the  anterior  one  third  and 
posterior  two  thirds  of  the  cords.  Such  lesions 
occurring  in  singers  require  strict  voice  rest  and 
then  gradual  reeducation.  If  the  nodules  become 
large  they  may  be  removed  endoscopically,  but 
unless  the  singer  learns  more  satisfactory  voice 
technics  they  will  recur. 

Specific  infections  such  as  tuberculosis  affect 
the  larynx  and  cause  hoarseness.  They  are  de- 
tected by  the  sputum  examination  and  the  X-ray 
films  of  the  chest.  Yet  these  simple  diagnostic 
procedures  are  too  often  overlooked  when  they 
should  be  routine  for  every  patient  who  has 
a voice  change.  Streptomycin  and  PAS  have 
spelled  a new  chapter  in  the  treatment  of  this 
condition. 

Paralyses  of  the  larynx  produce  hoarseness  by 
changing  the  tension  of  one  or  both  vocal  cords 
and  make  it  impossible  for  the  patient  to  control 
the  action  of  the  cords  as  they  attempt  to  break 
up  the  air  column  ascending  from  the  chest.  In 
unilateral  paralysis  one  flaccid  and  one  tense  cord 
cause  an  air  loss  which  accounts  for  the  breath- 
less type  of  whisper  characteristic  of  this  condi- 
tion. In  bilateral  paralysis  the  cords  lie  in  the 
midline,  and  although  they  are  flaccid  they  are 
equally  so  and  consequently  the  patient  with 
the  bilateral  paralysis  of  the  larynx  has  an  al- 
most normal  voice  while  the  patient  with  the 
unilateral  paralysis  is  hoarse  or  aphonic.  Failure 
of  the  function  of  abduction  in  bilateral  paralysis 
causes  the  severe  dyspnea  characteristic  of  this 
condition,  and  a tracheotomy  is  necessary  in 
most  cases.  The  causes  of  unilateral  paralysis 
may  be  listed  by  following  the  course  of  the 
nerve  from  the  base  of  the  skull,  through  the 
neck,  under  the  subclavian  vessels  on  the  right, 
touching  the  apex  of  the  lung,  returning  along 
the  esophagus  through  the  thyroid  gland  and 
into  the  larynx.  The  course  of  the  left  recurrent 
laryngeal  nerve  differs  since  it  {)asses  into  the 
chest  and  under  the  arch  of  the  aorta.  'Fhus, 
lesions  of  the  chest  as  well  as  the  neck  may  cause 
a paralysis  of  the  left  cord,  whereas  only  the 


lesions  in  the  neck  or  the  apex  of  the  right  lung 
will  be  responsible  for  lesions  of  the  right  cord. 
The  complicated  course  of  the  recurrent  laryn- 
geal nerve,  particularly  on  the  left,  makes  paraly- 
sis of  the  cords  an  index  of  pulmonary  disease  and 
therefore  valuable  in  diagnosis  and  prognosis. 

Functional  dysphonia  due  to  psychic  disturb- 
ances manifests  itself  in  a number  of  ways,  of 
which  hoarseness  is  often  a very  prominent  sign. 
The  mirror  examination  may  show  the  larynx  to 
be  normal  except  for  a small  air  loss  posteriorly 
as  the  cords  fail  to  approximate  in  the  posterior 
third.  In  such  instances  the  patient  has  a whis- 
pered type  of  voice.  In  other  manifestations  of 
this  condition  the  patient  speaks  with  extreme 
tension  and  fixation  of  the  diaphragm  in  a pat- 
tern which  is  so  characteristic  that  it  may  be 
detected  at  the  moment  the  patient  starts  to 
talk.  This  pattern  is  broken  in  the  sentences  or 
parts  of  sentences  that  follow  laughing,  and  this 
characteristic  is  recognized  readily  by  the  patient 
and  his  family.  The  management  of  such  a pa- 
tient is  left  to  the  psychiatrist  or  the  speech 
correction  therapist,  the  two  often  working  to- 
gether to  restore  a normal  voice. 

Neoplasms  of  the  larynx,  both  benign  and 
malignant,  cause  hoarseness  because  of  the  me- 
chanical block  between  the  vocal  cords  that  pre- 
vents their  approximation.  Benign  lesions,  such 
as  polyps,  edematous,  sessile  polypoid  changes 
along  the  cords,  and  solitary  papillomas  can  be 
removed  endoscopically  under  local  anesthesia 
to  restore  a clear  voice  in  a matter  of  minutes. 
Malignant  neoplasms,  on  the  other  hand,  require 
more  careful  study  in  order  to  help  the  surgeon 
choose  a method  of  therapy  which  will  give  the 
patient  the  best  opportunity  for  his  life. 

A large  majority  of  malignant  neoplasms  in 
the  larynx  are  squamous  cell  carcinomas  on  the 
vocal  cords  themselves.  They  give  an  early  warn- 
ing to  the  patient,  the  family,  and  the  physician 
when  the  voice  change  has  taken  place,  and  if 
the  warning  is  heeded,  an  early  accurate  diag- 
nosis can  be  made.  Farly  cancer  of  the  larynx  is 
almost  as  curable  as  early  cancer  of  the  skin. 
Rehabilitation  to  restore  a serviceable  voice  fob 


20 


Hoarseness — Hoi  i nger 


JANUARY,  1952 


lowing  minimal  procedures,  such  as  resection  of 
one  vocal  cord,  or  of  reeducation  of  the  patient 
following  the  more  radical  procedures,  is  now 
such  general  practice  that  most  patients,  even 
if  the  entire  larynx  is  removed,  return  to  their 
original  occupation  after  their  convalescence  and 
voice  training  program  have  been  completed. 
Cancer  of  the  larynx  in  younger  individuals  is 
being  seen  more  and  more  frequently  and,  there- 
fore, must  be  suspected  in  a patient  of  almost 
any  age  who  is  persistently,  progressively  hoarse. 
Cancer  of  the  larynx  is  extremely  common  and 
this  symptom  should  always  be  considered  in  the 
light  of  early  carcinoma  and  every  possible  diag- 
nostic means  used  to  detect  its  presence  or  to 
eliminate  it  from  further  consideration. 

The  diagnostic  steps  used  to  detect  the  causes 
of  hoarseness  are  simple  and  are  neither  time- 
consuming  nor  costly  to  the  patient.  They  must 
be  made  with  care  and  accuracy  and  with  the 
utmost  honesty  and  sincerity  of  the  physician 
with  himself,  to  the  end  that  every  portion  of  the 
larynx  is  adequately  and  thoroughly  inspected 
during  the  examination.  History  of  external 
trauma,  of  vocal  abuse,  of  onsets  of  hoarseness 
while  shouting,  of  foreign  body  aspirations,  etc., 
is  significant.  In  children  the  history  should  in- 
clude whether  or  not  the  child  has  had  immuni- 
zation for  diphtheria,  and  in  acute  infections  in 
an  adult  this  question  should  also  be  asked  and 
the  answer  recorded.  The  history  of  persistent, 
progressive  hoarseness  makes  one  consider  first 
and  foremost  the  possibility  of  a laryngeal  car- 


cinoma. Laboratory  studies  include  the  routine 
blood  tests,  the  X-ray  films  of  the  chest,  and  the 
sputum  examination. 

The  actual  examination  of  the  patient  includes 
a most  careful  mirror  examination  of  the  larynx. 
With  practice  and  with  a certain  degree  of  cau- 
tion the  larynx  may  be  inspected  with  a laryn- 
geal mirror  in  most  patients  without  the  use  of 
a local  anesthetic.  However,  should  gagging  be 
excessive,  a local  anesthetic  sprayed  into  the 
pharynx  may  be  used  to  facilitate  this  examina- 
tion. 

The  examination  should  never  be  considered 
completed  until  the  anterior  commissure  is  ade- 
quately inspected.  In  children  and  infants,  as  well 
as  in  adults  in  whom  even  the  addition  of  local 
anesthesia  is  not  sufficient  to  make  mirror  exam- 
ination of  the  larynx  possible,  a direct  examina- 
tion of  the  larynx  should  be  made  and  tissue 
removed  for  biopsy  for  a final,  accurate  patho- 
logic diagnosis. 

Thus,  hoarseness  is  usually  due  to  pathologic 
processes  involving  the  vocal  cords.  It  may  be 
due  to  inflammatory,  neurologic  or  neoplastic 
disease.  Careful  study  of  the  patient  and  par- 
ticularly thorough  inspection  of  all  the  cord  sur- 
faces by  mirror  or  direct  examination  will  estab- 
lish the  tentative  diagnosis  in  most  cases.  Final 
diagnosis  includes  the  laboratory  examinations, 
particularly  the  biopsy.  Therapy  is  dependent 
upon  diagnosis,  but  the  preservation  of  life  and 
the  restoration  of  voice  are  the  final  objectives 
to  be  reached,  the  latter  never  at  the  expense 
of  the  former. 


“THAT  FULL  FEELING  ’ 


WILLIAM  TRAVIS  GIBB,  JR.,  M.D. 

Washington 


HERE  are  many  symptoms  associated 
withdisturbancesof  the  gastrointestinal 
tract  that  are  extremely  common  yet  are  difficult 
to  explain  from  a physiologic  point  of  view.  They 
are  usually  part  of  a functional  disturbance  and 
clear  up  when  the  patient  as  a whole  is  made 
better;  One  of  the  most  interesting  of  these  is 
the  complaint  of  feeling  hungry  prior  to  a meal 
and  then,  after  taking  a few  bites,  being  satiated 
and  having  a sensation  of  distention  in  the  epi- 
gastrium. All  interest  is  subsequently  lost  in  the 
further  consumption  of  the  meal.  This  does  not 
happen  every  time  the  patient  sits  down  to  eat 
but  usually  occurs  when  there  is  some  sort  of 
emotional  tension  at  mealtime,  and  it  does  not 
happen  when  the  individual  is  diverted. 

A small  portion  only  of  the  patients  with  this 
complaint  have  organic  disease  of  the  stomach 
which  limits  its  capacity,  and  the  explanation  is 
quite  simple.  A large  gastric  neoplasm  and  ad- 
vanced linitis  plastica  are  good  illustrations.  The 
individual  who  has  undergone  an  extensive  gas- 
tric resection  will  suffer  this  way  postoperatively 
for  a time,  and  in  some  cases  the  complaint  will 
continue  indefinitely.  However,  the  vast  majority 
with  this  complaint  show  no  evidence  of  organic 
disease,  and  the  assumption  is  rightly  made  that 
it  is  functional  in  origin  and  part  of  a neurosis. 
Although  this  statement  is  true,  it  does  not  ex- 
plain the  symptom.  In  order  to  treat  a symptom 
properly  there  must  be  some  explanation  of  the 
mechanism  involved.  Eunctional  complaints  are 
as  a rule  subjective  and  therefore  almost  impos- 
sible to  re{)roduce  in  the  experimental  animal. 
The  study  of  a human  subject  is  unsatisfactory 
from  a purely  objective  viewpoint,  because  the 
particular  sym[)tom  cannot  be  consistently  re- 
produced. Therefore,  any  explanation  must  be  in 
great  part  hypothetical,  based  on  scattered  ob- 


servations and  impressions.  Such  is  the  case  in 
this  particular  instance. 

It  must  be  emphasized  first  that  the  stomach 
is  not  a flaccid  bag,  nor  can  it  be  likened  to  an 
elastic  rubber  container.  Its  walls  contain  two 
layers  of  muscle  laid  down  in  a very  complicated 
fashion.  These  muscle  layers  exhibit  varying  de- 
grees of  tone  and  activity.  All  parts  do  not  react 
simultaneously  to  the  same  degree.  The  tone 
may  vary  from  one  part  to  another,  depending 
upon  what  is  going  on.  There  is  active  relaxation 
and  contraction,  not  just  stretching  and  rebound. 
When  the  stomach  is  entirely  empty  the  walls 
are  in  apposition  and  there  is  little  or  no  actual 
lumen  space.  The  walls  are  thicker  because  the 
muscle  fibers  are  shortened.  The  surface  area  of 
the  muscular  portion  is  less  than  when  it  is  full. 
The  surface  area  of  the  mucosal  layer  is  the  same, 
however,  and  is  compensated  for  by  the  rugae 
which  become  higher  and  thicker,  with  the  inter- 
vening valleys  obliterated.  Most  of  this  goes  on  in 
the  body  of  the  stomach,  and  the  fundus  seems 
to  show  less  tonicity.  This  can  be  noted  by  means 
of  the  gastroscope  before  much  air  has  been 
introduced. 

The  empty  stomach  of  the  hibernating  bear, 
for  instance,  is  extremely  small  and  is  said  to  be 
“shrunken,”  suggesting  that  there  has  been  an 
actual  loss  of  substance.  When  the  animal  starts 
eating  in  the  spring,  he  begins  with  very  small 
amounts  of  food  and  in  a short  time  is  eating  in 
his  normal  way.  This  is  due  to  a gradual  relaxing 
of  the  increased  tonus  of  the  stomach,  not  to  the 
regeneration  of  muscle  tissue.  I am  sure  that  his 
hibernating  stomach  has  exactly  the  same  num- 
ber of  muscle  fibers  as  when  he  is  eating  his  usual 
diet. 

When  one  examines  the  normal  stomach  radio- 
logically  while  the  patient  is  in  the  upright  posi- 


21 


97 


^^That  Full  Feeling" — Gibb 


JANIZARY,  1952 


tion,  it  is  usually  noted  that  the  first  swallow  or 
so  remains  in  the  fundus  for  a short  time  before 
dropping  to  the  most  dependent  portion  of  the 
greater  curvature.  Thereafter  the  remaining  por- 
tion of  the  meal  flows  in  readily.  I'his  suggests 
that  the  tonus  of  the  body  of  the  stomach  is 
different  from  that  of  the  fundus  when  it  is 
empty,  and  that  food  in  the  fundus  in  some  way 
causes  the  walls  of  the  body  to  relax.  1 do  not 
feel  that  it  is  just  the  weight  of  the  barium  in 
the  fundus  that  accomplishes  this.  In  certain 
instances  the  barium  remains  in  the  fundus  for  a 
considerable  length  of  time  and  the  patient  com- 
plains of  feeling  full  and  will  not  drink  any  more 
barium  until  the  body  relaxes  and  the  fundus  is 
empty.  Thereafter  he  ingests  the  rest  of  the 
meal  without  any  complaint. 

It  has  been  my  experience  over  a period  of 
years  that  those  patients  who  complain  of  the 
previously  mentioned  full  feeling  after  a few  bites 
show  this  sort  of  a reaction  to  a marked  degree. 
In  other  words,  the  tonus  of  the  body  of  the 
stomach  is  excessive,  and  this  part  does  not  relax 
normally  when  food  enters  the  fundus.  The  food 
remains  in  the  fundus  for  some  time  and  slightly 
distends  that  part  of  the  stomach,  thereby  doing 
away  with  the  feeling  of  hunger,  hi  other  words, 
at  that  particular  time  the  stomach,  or  rather 
that  part  of  it  which  is  ready  to  receive  food,  is 
actually  full.  The  appearance  presented  should 
not  be  confused  with  a true  cascade  stomach. 
Probably  many  reported  cascade  stomachs  are 
based  on  this  mechanism  and  are  not  a true 
anatomic  abnormality.  When  such  a patient  is 
behind  the  fluoroscopic  screen  and  after  taking 
a few  swallows  claims  she  can  take  no  more,  the 
roentgenologist  by  means  of  a soothing  and  re- 
assuring approach  can  cause  the  body  of  the 
stomach  to  relax  and  the  examination  can  pro- 
ceed in  the  usual  way. 

The  case  which  brought  the  idea  of  this  mecha- 
nism to  my  attention  came  under  my  care  many 
years  ago.  The  lady  in  question  was  aliout  55 
years  of  age  and  had  been  a friend  of  my  family 
for  many  years.  She  was  undernourished  and 
high-strung  and  was  famous  in  her  social  circle 


because  of  her  “tiny  stomach.”  Her  friends  were 
convinced  that  she  had  a bird-sized  stomach,  and 
she  ate  accordingly.  Finally  it  was  necessary  to 
examine  this  phenomenon  radiologically.  Actu- 
ally her  stomach  was  enormous;  the  most  depend- 
ent portion  rested  on  her  bladder  when  she  was 
in  the  upright  position.  Initially,  however,  the 
first  swallow  remained  in  the  fundus  indefinitely, 
until  finally  after  much  conversation  and  diver- 
sion the  barium  dropped  down. 

Although  there  is  no  scientific  proof  as  such, 
the  origin  of  this  mechanism  is  probably  central, 
a selective  vagal  effect,  and  not  in  the  stomach 
itself.  There  is  a possibility  that  there  might  be 
a humoral  mechanism  working  through  the  hypo- 
thalamus, the  pituitary  and  the  adrenals.  In 
general  the  patients  are  thin  and  undernourished, 
tense  and  neurotic,  and  have  long,  fishhook  types 
of  stomach.  They  frequently  have  curious  ideas 
of  what  they  can  and  what  they  cannot  eat.  The 
whole  thing  stems  from  a psychologic  reaction, 
and  there  are  probably  many  such  causes.  Long 
years  of  unsupervised  dieting  in  order  to  main- 
tain an  overly  slim  figure  may  contribute  in 
many  instances. 

The  treatment  of  this  symptom  consists  of 
treating  the  patient  as  a whole.  Although  this 
may  be  the  chief  complaint,  there  are  many  other 
symptoms  as  well.  The  personality  of  the  patient 
must  be  thoroughly  evaluated,  and  this  can  usu- 
ally be  accomplished  by  the  average  physician. 
The  specialized  services  of  a psychiatrist  need  not 
be  employed  necessarily.  Sometimes  a demon- 
stration in  the  fluoroscopic  room,  with  a mirror 
being  used  so  that  the  patient  can  see  that  her 
stomach  is  perfectly  well  able  to  hold  any  reason- 
able amount  of  food,  will  suffice.  Sometimes  there 
is  excessive  swallowing  of  air  with  food  and  drink, 
and  this  also  can  be  shown  to  the  patient  radio- 
graphically. Many  of  these  people  make  a great 
commotion  about  the  ingestion  of  food,  taking 
tiny  sips  of  liquid  and  minute  bites  of  solid  food, 
and  swallowing  each  time  with  great  effort  and 
apparent  difficulty.  Probably,  if  the  truth  were 
known,  they  could  eat  as  much  as  they  wanted 
{Continued  on  page  60) 


FAMILIAL  PATTERN  IN  PEPTIC  ULCER 


Report  of  a Family  and  Review  of  the  Literature* 

KDWARI)  WASSERMAN,  M.Dj 

Resident,  Fifth  and  Sixth  Medical  Services  {Boston  University), 
Boston  City  Hospital 

MORRIS  RINGER,  M.D. 

Resident,  Fifth  and  Sixth  Medical  Services  {Boston  University), 
Boston  City  Hospital 


FAMILIAL  pattern  of  peptic  ulcer 
obtained  from  one  family  prompted  us  to  in- 
vestigate the  individual  cases  and  to  review  the 
literature  briefly. 


Report  or  Cases 


to  an  ulcer  diet  in  association  with  the  use  of  antacids 
and  antispasmodics. 

Son  No.  3.  Epigastric  pain  between  meals  appeared 
at  the  age  of  20.  This  member  has  never  had  a gastro- 
intestinal X-ray  examination,  but  his  symptoms  are  re- 
current and  he  requires  treatment  with  a bland  diet  and 
antacids  in  order  to  obtain  relief. 


The  Father.  At  the  age  of  34  he  developed  epigastric 
distress  between  meals  which  was  relieved  by  means  of 
food  and  alkali.  X-ray  examination  at  this  time  revealed 
a duodenal  ulcer.  One  year  later  he  was  hospitalized  be- 
cause of  a bleeding  duodenal  ulcer.  On  a regimen  of  bland 
diet  and  antacids  he  remained  asymptomatic  during  the 
following  8 years.  The  ulcer  perforated  when  he  was  43 
and  required  surgical  repair.  In  the  ensuing  9 years  he  has 
had  occasional  episodes  of  heartburn  and  epigastric  dis- 
tress which  are  readily  controlled  by  diet  and  .Amphogel. 

Son  No.  1.  He  first  noted  gnawing  epigastric  discom- 
fort relieved  by  eating  at  the  age  of  20.  One  year  later, 
X-ray  examination  in  the  Navy  revealed  a duodenal 
ulcer,  because  of  which  he  received  a medical  discharge. 
Repeated  radiographic  examinations  during  the  follow- 
ing 6 years  have  shown  the  presence  of  a chronic  duodenal 
scar.  .At  present  infrequent  attacks  of  epigastric  pain  are 
promptly  relieved  by  the  u.se  of  antacids. 

Son  No.  2.  He  underwent  surgical  repair  of  a per- 
forated duodenal  ulcer  without  a previous  ulcer  history 
at  the  age  of  18.  I'ollow-uj)  roentgenograjjhic  studies 
during  the  next  6 years  have  revealed  a chronic  duodenal 
ulcer.  Symptoms,  including  ej)igastric  distress  radiating 
through  to  his  back,  are  rapidly  controlled  by  adherence 


* From  the  Clastrointeslinal  (,'linic  of  Boston  City  Hosi)ital, 
Boston,  Mass. 

t Now  engaged  in  the  [)rivale  practice  of  medicine  in 
Bridgeport,  Conn. 


Daughter  No.  1.  .At  the  age  of  28  she  had  epigastric 
distress  between  meals  and  at  night,  which  was  relieved 
by  food  or  antacids.  X-ray  examinations  were  never  ob- 
tained, but  the  symptoms  are  well  controlled  by  the  use 
of  a bland  diet  and  antacid  administration. 

Discussion 

Many  clinicians  have  been  impressed  by  a 
familial  pattern  in  diseases  of  the  gastrointestinal 
tract.  This  could  be  caused  by  some  factor  or 
factors  in  the  common  environment  of  such  a 
family  group,  or  perhaps  by  an  hereditary  ele- 
ment. It  is  possible  that  both  factors  must  co- 
exist for  the  formation  of  an  ulcer.  No  substantial 
evidence  has  been  presented  to  support  either  of 
these  theories.  Dreschfeld'  in  1897  described  6 
families,  each  of  which  had  2 members  with  pep- 
tic ulcers.  Another  group,  comprised  of  a mother 
and  i sons  with  duodenal  ulcers  and  a fourth 
son  with  a gastric  ulcer,  was  reported  by  Huddy'^ 
in  1925.  family  was  mentioned  by  Bockus^ 
in  which  a father,  4 sons,  and  1 daughter  were 
treated  for  jieptic  ulcer.  Similar  reports  have 
been  published  by  others.''"®  Some  of  these  au- 
thors are  not  specific  as  to  whether  the  location 
of  the  lesion  was  duodenal  or  gastric.  Several 
such  cases  were  diagnosed  from  the  history  alone 


23 


24 


Familial  Pattern  in  Peptic  Ulcer — W asserman  and  Ringer  jaistuary,  1952 


without  the  benefit  of  confirmation  by  roentgeno- 
graphic  studies.  There  are  reports  of  twins,  both 
monozygotic  and  dizygotic, who  developed 
peptic  ulcers  at  a similar  period  in  life.  Several 
authors  have  speculated  as  to  the  mechanism  of 
heredity  involved  in  this  familial  incidence  of  pep- 
tic ulcer.  Reich*"*  described  a family  with  5 cases 
of  gastric  ulcer  in  4 generations.  He  felt  that  it 
w'as  a dominant  factor  which  was  not  sex-linked. 
Others*^  have  called  it  “an  irregular  dominant 
factor  more  frequent  in  males.”  On  the  other 
hand,  Bauer  and  Aschner*®  considered  the  factor 
for  ulcer  to  be  a recessive  one. 

In  the  family  reported  here,  the  father,  3 sons, 
and  1 daughter  were  involved.  Another  son  and 
daughter,  the  youngest  members  of  the  family, 
have  no  known  gastrointestinal  dysfunction.  The 
remainder  of  the  family  history,  so  far  as  could 
be  elicited,  was  also  negative  for  peptic  ulcer. 


BIBLIOGRAPHY 

1.  Dreschfeld,  J.,  in  .\  System  of  Medicine,  edited  by 

.\llbutt,  T.  C.  New  York;  Macmillan,  1897,  3,  520. 

2.  Huddy,  G.  P.  B.:  Lancet,  1925,  209,  276. 

3.  Bockus,  H.  L.:  Gastroenterology.  Philadelphia:  Saunders, 

1946. 

4.  Rieker,  H.  H.:  .\nn.  Int.  Med.,  1933,  7,  732. 

5 Turner,  E.  L.,  .vnd  Lattuf,  A.  G.:  Presse  Med.,  1935, 
43,  339. 

6.  Helweg-Larsen,  H.  F.  : .\cta.  med.  scandinav.,  1946, 

125,  63. 

7.  Hurst,  .\.  F. : Guy’s  Hosp.  Rep.,  1921,  19,  450. 

8.  Huber,  : Mtinchen.  med.  Wchnschr.,  1907,  54,  204. 

9.  Wilkie,  D.  P.  D.:  Lancet,  1927,  2,  1228. 

10.  McHardy,  G.,  .and  Browne,  D.  C.:  J..-\.M..\.,  1944,  124, 

.S03. 

11.  Kudu,  C.  W.:  Brit.  M.  J.,  1938,  1,  449. 

12.  Philipowicz,  j.  : Wien.  klin.  Wchnschr.,  1949,  61,  333. 

13.  Perez,  F.  R.:  Rev.  din.  espan.,  1947,  26,  337. 

14.  Reich,  F.  : Ztschr.  f.  indukt.  .\bstamnungs-  u.  Verer- 

bungsL,  1925.  38,  258. 

15.  Lever,  .\.  F.,  and  Kucher,  B.  .4.:  Proc.  Med.  Biol. 

Inst.  Moscow,  1934,  3,  148. 

16.  Bauer,  J.,  and  .Aschner,  B.:  Klin.  Wchnschr.,  1922,  1 

1250. 


PERFORATION  OF  A FISH  BONE  THROUGH  THE 
DUODENUM  INTO  THE  PORTAL  VEIN  RESULT- 
ING IN  STREPTOCOCCUS  SEPTICEMIA  AND 
DEATH 

ALLEN  WIDOME,  M.D. 

f Associate  in  Anesthesia,  Columbia  Hospital,  Washington 


Report  of  Case 

B.  C.  S.,  a 24-year-old  colored  man,  walked  into  the 
hospital  clinic  giving  a history  of  chills,  fever,  nonpro- 
ductive cough  and  malaise  for  24  hours.  The  past  history 
was  essentially  negative  except  for  intermittent  attacks 
of  diarrhea  since  the  age  of  10,  with  3 to  4 watery  stools 
daily  during  an  attack.  The  stools  contained  no  gross 
blood.  Approximately  a month  before  this  admission 
he  was  seized  with  severe  periumbilical  pain  which  radi- 
ated to  his  back.  He  sought  medical  aid  and  was  admitted 
to  a hospital  in  another  city.  The  physician  who  treated 
him  could  not  be  contacted,  but  according  to  the  records 
he  did  not  consider  the  patient  seriously  ill,  since  noth- 
ing of  significance  was  found  on  physical  examination  and 
the  white  blood  cell  count  and  differential  white  blood 
cell  count  were  within  normal  limits.  He  was  discharged 
after  24  hours  of  observation.  The  patient  stated  that 
after  discharge  he  continued  experiencing  vague,  epi- 
gastric abdominal  pains  radiating  to  his  back. 

Physical  examination  on  admission  revealed  a well- 
developed  colored  man  who  appeared  acutely  ill  although 
he  walked  into  the  hospital.  The  temperature  was 
104.2°F.,  the  pulse  rate  108,  and  the  respiratory  rate  24. 
Examination  of  the  abdomen  revealed  moderate  tender- 
ness over  the  entire  upper  portion  with  only  slight  muscle 
spasm.  The  white  blood  cell  count  was  18,400,  with  92 
per  cent  polymorphonuclears,  5 per  cent  lymphocytes, 
and  3 per  cent  monocytes;  of  the  polymorphonuclears, 
60  per  cent  were  segmented,  29  per  cent  were  stab  cells, 
2 per  cent  were  juveniles,  and  1 per  cent  were  myelocytes 

The  next  morning  the  temperature  fell  to  normal,  but 
thereafter  it  began  to  spike  with  evening  rises  of  tempera- 
ture to  102°-103°F.,  accompanied  by  severe  shaking 
chills.  The  possibility  of  malaria  was  thought  of,  but 
blood  smears  were  negative.  Three  days  after  admission 
the  abdominal  pain  became  more  severe  and  increasing 
rigidity  of  his  upper  abdominal  muscles  developed,  es- 
pecially on  the  right.  Because  of  these  findings  we  deemed 
it  advisable  to  perform  a laparotomy,  having  in  mind  the 
possibility  of  acute  cholecystitis.  At  this  time  a blood 
culture  had  been  taken,  but  the  results  had  not  been 
reported.  At  operation  the  gall  bladder  was  reddened  and 
slightly  distended.  Cholecystotomy  was  performed,  and 
the  patient  was  returned  to  his  room  in  poor  condition. 

The  blood  culture  was  reported  on  the  day  following 


surgery  as  being  positive  for  Streptococcus  hemolyticus . 
The  patient  was  given  extensive  antibiotic  therapy  and 
small  blood  transfusions.  Despite  this  therapy  the  blood 
cultures  remained  positive  and  a portion  of  the  liver 
eviscerated  a week  postoperatively.  Some  jaundice  ap- 
peared at  this  time  and  gradually  increased  in  intensity. 
The  course  was  downhill,  and  death  occurred  28  days 
after  admission. 

At  necropsy  the  peritoneal  cavity  was  found  to  con- 
tain about  2 liters  of  yellowish,  clear  fluid.  The  mesentery 
contained  a number  of  soft,  enlarged,  discrete  lymph 
nodes.  There  was  marked  elevation  of  the  diaphragm. 
The  liver  was  greatly  enlarged,  extending  below  the  costal 
margin  for  6 to  8 cm.  The  spleen  weighed  760  grams  with 
a smooth  capsule  and  regular  outline.  On  section  the  pulp 
was  seen  to  be  soft  and  dark  purple,  and  to  have  indistinct 
trabeculae.  The  pulp  scraped  away  as  gelatinous,  clot- 
like masses.  To  the  naked  eye,  the  entire  duodenal  mucosa 
appeared  intact  and  there  was  no  evidence  of  scarring. 
The  structure  was  adherent,  however,  posteriorly  to  the 
portal  triad  almost  throughout  their  point  of  contact. 
The  liver  weighed  3,465  grams.  There  were  a number  of 
firm  adhesions  between  the  medial  extremity  of  the  right 
lobe  and  the  abdominal  wound.  The  surface  was  other- 
wise smooth,  and  the  margins  were  sharp.  Near  the  lateral 
margin  of  the  left  lobe  was  an  elevated  area  4 cm.  in 
diameter  with  slight  irregularity  of  the  surface  because  of 
the  projection  of  innumerable,  yellowish,  pus-filled  la- 
cunae ranging  from  0.2  to  1 cm.  in  diameter.  Section 
through  remaining  portions  of  the  liver’ disclosed  hun- 
dreds of  similar  collections  of  small  abscesses  throughout 
the  substance.  Branches  of  the  portal  vein  could  be 
traced  in  most  of  these.  Even  where  there  were  no  ab- 
scesses the  portal  radicles  were  prominent  with  their 
walls  greatly  thickened.  On  section  into  the  portal  vein 
where  it  entered  the  liver  and  before  division,  an  abscess- 
like cavity  about  2 cm.  in  diameter  proved  to  be  a friable 
thrombus  adherent  to  a thickened  vein  wall,  the  remain- 
ing space  being  occupied  by  fluid  pus.  Embedfled  in  the 
clot  was  a needle-like  structure  3 cm.  in  length  and  about 
0.1  cm.  in  diameter  with  the  characteristic  curve,  con- 
sistency, and  appearance  of  a fish  bone.  This  body  had 
part  of  its  length  within  the  vein  lumen  and  j)art  em- 
bedded in  the  j)()sterior  wall. 

{Continued  on  page  60) 


25 


aae 


SOCIETY  AND  THE  PHYSICIAN  ' 

VII.  Professional  Courtesy 


The  courtesy  of  treating  other  physicians  and  their  families  without  charge  is  well  ac- 
cej)ted  and  often  is  extended  to  nurses,  dentists,  druggists,  and  others  with  whom  we  have 
professional  contact.  With  the  custom  I have  no  quarrel  and  have  often  been  the  recipient 
as  well  as  donor  of  such  courtesy.  However,  I did  not  have  such  courtesy  in  mind  when 
writing  this  page. 

I’m  thinking  in  terms  of  the  more  generally  accejRed  definition  of  “courtesy”  and  how  it 
applies  to  the  medical  profession.  How  courteous  are  our  relations  with  our  patients,  our 
nurses,  our  hospital  personnel,  and  with  our  fellow  physicians? 

I recall  surgeons  who  have  the  unfortunate  habit  of  throwing  instruments  when  they 
aren’t  doing  well,  of  swearing  loud  and  long  when  they’re  annoyed,  of  blaming  nurses,  resi- 
dents and  orderlies  when  they  get  into  difficulties.  They  are  “never  wrong  themselves.” 
Someone  else  is  always  at  fault.  Such  lack  of  consideration  and  courtesy  is  soon  mirrored  in 
the  attitude  of  those  who  have  to  work  with  them.  Lack  of  cordiality,  grudging  service,  and 
avoidance  are  their  harvest. 

'I'he  commonest  complaint  patients  make  about  doctors  isn’t  that  they  charge  too  much 
or  don’t  render  good  medical  care,  but  that  the  doctor  never  tells  them  anything.  We  all  know 
that  some  patients  talk  endlessly,  others  don’t  absorb  what  we  tell  them,  and  others  yet  put 
an  unintended  interpretation  on  what  we  have  to  say.  In  spite  of  this,  I believe  the  most  satis- 
fied and  cooperative  patient  is  the  one  who  has  been  offered  the  courtesy  of  exjrlaining  his  or 
her  trouble,  and  in  turn  has  received  a reasonable  explanation  of  what’s  wrong,  what  is  going 
to  be  done  about  it,  and  what  can  be  expected  from  the  treatment. 

Unwittingly,  physicians  are  often  discourteous  to  other  physicians  and  this  at  times 
creates  problems  for  both.  All  too  often  when  a patient  goes  to  another  physician  for  reassur- 
ance or  another  opinion,  the  question  is  abruptly  asked,  “Who  in  the  world  put  bifocals  on 
you?”  or,  “Who  used  radium  on  this  lesion?”  or,  “Why  would  anyone  suggest  surgery  for 
what  you  have?”  These  thoughtless  and  seemingly  innocent  questions  cast  doubt  on  the 
integrity  and  intelligence  of  the  other  physician,  undermine  the  patient’s  confidence  in  the 
medical  profession  (and  you),  and  at  times  pave  the  way  for  a lawsuit  which  could  readily 
have  been  avoided.  While  it  is  neither  honest  nor  wise  to  cover  up  for  intentional  misdeeds 
of  others,  the  courteous  understanding  of  the  other  physician’s  viewpoint  is  essential  to  good 
public  and  professional  relations. 


HSA— A TRIED  AND  PROVEN  AGENCY 

Editor’s  Note:  The  following  article,  written  for  the  Medical  Annals,  constitutes  a farewell  message  from  the 
late  Dr.  Oscar  B.  Hunter,  Sr.  Comiileted  only  a few  hours  before  his  death,  it  is  written  with  the  vigor  and  frankness 
which  characterized  everything  he  did.  In  it  he  counsels  wisely  on  a matter  which  was  close  to  him  and  which  is  of 
vital  concern  to  the  medical  profession  and  the  people  of  this  community. 


Some  years  ago  physicians  in  this  community 
found  that  they  were  giving  their  services  free 
to  ward  patients  in  the  hospitals  who  should  be 
paying  not  only  for  hospitalization  but  for  medi- 
cal care.  This  was  true  to  such  an  extent  that 
many  physicians  refused  to  contribute  to  the 
Community  Chest.  Through  the  Committee  on 
Medical  Economics  of  the  Medical  Society,  the 
situation  was  brought  to  the  attention  of  the 
Community  Chest,  which  moved  to  establish  a 
central  admitting  bureau  through  which  all  medi- 
cally indigent  patients  would  be  cleared.  Under 
this  plan  Community  Chest  money  was  used  to 
pay  the  hospital  and  the  patient  repaid  over  a 
period  of  time  to  the  extent  possible.  Once  physi- 
cians were  assured  that  a patient  was  medically 
indigent  and  worthy  to  receive  Community 
Chest  assistance  in  paying  the  hospital,  they 
were  willing  to  give  their  professional  services 
without  fee.  The  Medical  Society  contributed 
nearly  $10,000,  which  was  used  with  money  allo- 
cated by  the  Washington  Community  Chest,  to 
establish  a Central  Admitting  Bureau  which  be- 
gan to  function  on  January  1,  1935.  This  Central 
Bureau,  now  known  as  the  Hospital  Service 
•Agency,  is  a nonprofit  corporation  on  which 
there  is  equal  representation  of  the  medical  and 
dental  professions,  the  hospitals,  and  the  con- 
tributing {lublic  which  sufiports  the  Community 
Chest. 

Since  1935,  Community  Chests  have  been  es- 
tablished in  the  nearby  counties  of  Maryland 
anrl  Virginia.  These  chests  have  jointly  estab- 
lished the  Community  Chest  fiederation,  which 


annually  conducts  the  Red  leather  campaign. 
I'his  campaign  supports  all  of  the  Community 
Chests  and  their  member  agencies.  The  Red 
I'eather  campaign  recently  completed  raised 
more  money  than  in  any  year  since  the  end  of 
World  War  II.  In  this  campaign  the  solicitation 
of  physicians  was  organized  under  the  leadership 
of  one  of  our  own  members.  Dr.  W.  Ross  Morris. 
The  Medical  Society  takes  pride  in  the  fact  that 
the  physicians  have  exceeded  their  (piota  in  the 
campaign. 

With  the  growth  of  population  in  the  Metro- 
politan Area,  the  Hospital  Service  .Agency  has 
expanded  its  activities  so  far  as  deemed  neces- 
sary by  its  Board  of  Trustees  to  investigate  the 
circumstances  of  medically  indigent  patients  in 
the  District  of  Columbia  and  nearby  counties, 
and  to  certify  their  worthiness  to  receive  financial 
assistance.  Totally  indigent  persons,  if  legal  resi- 
dents of  the  community,  can  be  hos[)italized  at 
tax  e.xpense. 

In  developing  its  functions  under  policies  es- 
tablished by  its  representative  Board  of  Trustees, 
Hos[)ital  Service  -Agency  has  steadfastly  ad- 
hered to  the  principle  that  the  medically  indi- 
gent patient  should  pay  for  his  own  care  to  the 
extent  possible  and  receive  assistance  only  to 
the  extent  necessary.  The  apjilication  of  this 
principle  has  resulted  in  collections  from  part- 
[)ay  patients  .sufficient  not  only  to  cover  the  cost 
of  HS.A’s  own  administration  but  to  add  sub- 
stantially to  the  hos[)italization  fund  allocated 
by  the  Community  Chest.  'Fhe  use  of  contributed 
(('ommunity  Chest)  funds  to  hel])  the  medically 


27 


Editorials 


JANUARY,  1952 


indigent  at  the  time  of  need,  with  ultimate  re- 
payment by  the  patient,  has  always  been  con- 
siflered  one  of  the  most  ajjproved  and  worthwhile 
aspects  of  HSA’s  plan  of  operation. 

About  a year  ago  one  of  the  county  Com- 
munity Chests  withdrew  from  its  affiliation  with 
the  Hospital  Service  Agency  and  set  up  its  own 
[)lan  for  investigating  medical  indigency  and 
paying  for  hospitalization  with  free  medical  care 
by  physicians.  That  Community  Chest  is  now 
appealing  to  its  county  government  to  take  over 
resj)onsibility  for  providing  hospital  care  to  all 
patients  unable  to  pay.  At  present  the  county 
governments  provide  care  for  ta.x-eligible  pa- 
tients either  through  USA  or  by  formal  con- 
tracts with  voluntary  hospitals,  most  of  which 


are,  of  course,  in  the  Dis- 
trict of  Columbia.  The 
District  Government  as 
far  as  possible  provides 
hospital  care  for  tax-eli- 
gible patients  at  Gallin- 
ger  Municipal  Hospital. 

It  has  contracts,  how- 
ever, with  eight  local 
hospitals  to  care  for 
emergency  admissions 
and  outpatient  care. 
These  contract  hospitals 
are  paid  from  a fund 
known  as  the  Medical 
Charities  Fund  appro- 
priated by  Congress  in 
the  annual  appropria- 
tion for  the  District  of 
Columbia.  The  District 
Health  Department  ad- 
ministers this  fund 
through  its  Bureau  of 
Medical  Assistance, 
which,  like  the  Hospital 
Service  Agency,  arranges  j 
accounts  receivable  from  j 
patients  able  to  pay.  I 
Payments  from  tax-eli-  | 
gible  patients,  however,  are  made  to  the  Collec- 
tor of  Ta.xes  and  go  into  the  general  funds  of  the  ' 
U.  S.  Treasury,  thus  becoming  unav^ailable  for 
any  addition  to  the  Medical  Charities  Fund. 

.\s  stated  above,  payments  by  HSA-certihed 
patients  are  added  to  the  Hospitalization  Fund 
provided  through  the  Red  Feather  campaign. 

The  District  of  Columbia  Community  Chest, 
now  known  as  United  Community  Services,  has 
decided  to  allocate  its  own  fund  for  hospitaliza- 
tion of  nontax-eligible  patients  instead  of  having 
it  allocated  for  them  by  the  Community  Chest 
Federation  as  in  the  past.  As  of  this  writing, 
CCS  is  considering,  through  its  Hospitalization 
Committee,  whether  to  have  its  hospitalization 


MEDICAL  LEADERS  IN  THE  RED  FEATHER  CAMPAIGN 

Dr.  Frank  D.  Costenb.vjjer,  President  of  the  Medical  Society  of  the  District  of  Colum- 
bia, AND  Dr.  \V.  Ross  Morris,  Chairman  of  the  Physicians  Group,  are  shown  discussing  the 
ojiening  of  the  1952  Red  Feather  Campaign  of  the  United  Community  Services  with  the 
Campaign  Chairman,  Mr.  Thornton  VV.  Owen.  This  picture  was  taken  in  front  of  the 
Hospital  Service  .\gency  booth  at  the  Medical  Society’s  22nd  Annual  Scientific  .\ssembly. 
HS.\  is  a Communitjr  Chest  agency. 

The  Physicians  Group  contributed  more  than  114  per  cent  of  its  quota  in  the  Red  Feather 
Campaign.  Most  of  the  credit  for  this  success  is  due  Dr.  Morris,  who  was  tireless  in  his  efforts 
to  “top”  the  doctors’  quota. 


VOL.  XXI,  NO.  1 


Medical  Annals  of  the  District  of  Columbia 


29 


fund  continue  to  be  administered  by  HSA,  origi- 
nally established  by  the  Community  Chest  and 
the  Medical  Society,  or  to  have  it  administered 
by  some  other  agency,  central  or  otherwise. 

The  Medical  Society  will  watch  with  interest 
the  progress  of  the  UCS  in  arriving  at  its  deci- 
sion. We  have  found  during  the  seventeen  years 
of  its  existence  that  HSA  has  adapted  its  func- 
tions to  the  changing  needs  of  the  community. 
It  has  taken  on  additional  activities  not  met  by 
any  other  agency  and  it  has  discontinued  some 
of  its  original  activities  when  they  were  found 
no  longer  necessary  or  when  it  was  found  the 

NEW  HOPE 

Recently  the  Medical  Society  of  the  District 
of  Columbia  was  told  in  an  interesting  discussion 
by  Dr.  Paul  D.  White  of  Boston  that  the  “good 
old  days”  were  not  so  very  good.  He  recalled 
that  40  years  ago  diagnosis  in  the  field  of  heart 
and  vascular  disease  was  faulty  by  present-day 
standards,  and  that  treatment  was  poor.  He 
told  of  the  continuing  need  and,  in  some  age 
groups,  increasing  problem  of  these  diseases 
which  far  outstrip  all  others  as  a cause  of  death. 
However,  he  pointed  cut  definite  advances  in 
treatment  that  have  taken  place  in  the  past  2 
decades.  To  help  continue  the  advances  against 
heart  and  vascular  disease  the  Washington  Heart 
Association  in  affiliation  with  the  American 
Heart  Association  in  its  campaign  for  funds  this 
year  actively  promotes  this  feeling  of  optimism 
in  “New  Hope  for  Hearts.” 

“New  Hope  for  Hearts”  is  more  than  a slogan. 
'I'here  is  real  meaning  in  the  phrase.  The  inci- 
dence of  rheumatic  fever  and  rheumatic  heart 
disease  has  been  falling  steadily  in  the  past  50 
years,  and  this  decline  preceded  the  present-day 
use  of  antibiotic  and  hormonal  therapy.  This  is 
probably  a reflection  for  the  most  part  of  better 
living  conditions.  ACTH  and  cortisone  are  new 
tools  in  the  therapy  of  rheumatic  fever,  but  their 
true  value  is  yet  to  be  determined.  The  anti- 
biotics of  course  have  found  a definite  place  in 


need  for  them  was  being  met  by  other  agencies. 
Physicians  have  demonstrated  their  willingness 
to  cooperate  with  the  local  and  with  other  Com- 
munity Chests  in  providing  hospital  care  for 
nontax-eligible  medically  indigent  persons,  but 
they  will  regard  with  apprehension  any  move  to 
shift  from  a tried  and  proven  agency  to  an  un- 
tried new  agency  the  responsibility  for  adminis- 
tering Red  Feather  Funds  which  they  have 
helped  to  raise  and  which  have  been  allocated 
for  hospitalization  of  patients  which  they  are 
expected  to  serve  without  fee. 

Oscar  B.  Hunter,  Sr.,  M.D. 

FOR  HEARTS 

the  prevention  of  rheumatic  fever.  So  in  the 
field  of  rheumatic  heart  disease  there  is  real 
hope.  Bacterial  endocarditis,  formerly  fatal  in 
all  instances,  in  less  than  10  years  has  become 
curable  in  most  by  adequate  penicillin  or  like 
substances.  There  have  been  tremendous  and 
dramatic  strides  made  in  the  field  of  cardio- 
vascular surgery — the  cure  of  patency  of  the 
ductus  arteriosus  and  coarctation  of  the  aorta, 
the  improvement  of  patients  with  tetralogy  of 
Fallot,  congenital  tricuspid  stenosis,  and  pure 
pulmonary  stenosis,  and  most  recently  help  for 
patients  with  rheumatic  heart  disease  by  val- 
vulotomy and  commissurotomy.  Research,  both 
medical  and  surgical,  is  going  forward  in  the 
fields  of  hypertensive  and  coronary  heart  dis- 
ease, and  we  hope  there  will  be  success  in  the 
not  too  distant  future  in  this  attempt  to  pro- 
long useful  lives. 

The  great  improvement  in  health  outlook  since 
the  “good  old  days”  stems  from  many  factors, 
the  most  important  of  which,  of  course,  has  been 
research.  The  Washington  Heart  Association 
gives  25  per  cent  of  the  funds  collected  in  its 
cam[)aign  to  the  American  Heart  Association 
for  use  under  its  direction  for  research  wherever 
and  however  the  American  Heart  Association 
believes  there  is  need  for  research  funds  and 
promise  of  benefit  for  everyone.  Last  year  the 


30 


Editorials 


JANUARY,  1952 


American  Heart  Association  and  its  affiliates 
allocated  $1,250,000  to  heart  and  vascular  re- 
search. It  appointed  the  first  of  a series  of  Career 
Investigators.  'Fhis  inaugurated  a form  of  sup- 
port for  research  that  is  unique  among  national 
health  organizations.  Ten  per  cent  of  the  funds 
collected  by  the  Washington  Heart  Association 
is  used  for  research  carried  on  in  our  own  local 
hospitals  and  medical  schools.  It  brings  leaders 
in  research  to  Washington  to  tell  us  of  advances 
elsewhere  in  the  field  of  cardiovascular  disease. 

d'he  remainder  of  the  funds  collected  is  used 
for  community  service.  Thousands  of  leaflets 
of  instruction  have  been  distributed.  Have  you 
received  “Examination  of  the  Heart”  which  the 
Washington  Heart  Association  made  available  to 
physicians  of  this  area?  Do  you  have  the  “Cook 
Book  for  the  Salt- Free  Diet”  to  give  to  your 
patients?  Those  are  only  2 of  several  informative 
booklets.  The  camp  for  children  with  heart  dis- 
ease has  l^een  again  a deeply  appreciated  success 
for  some  120  children.  And  there  is  now  an  oc- 
cupational therapy  department  for  the  home- 
l)ound  cardiac  patients;  adults  disabled  by  the 
effects  of  heart  or  vascular  disease  are  visited 


weekly  and  efforts  toward  rehabilitation  are  car- 
ried on.  Incidentally,  patients  for  occupational 
therapy  may  be  referred  by  private  physicians 
as  well  as  by  hospitals  or  clinics,  a fact  that  may 
not  be  widely  known. 

The  Washington  Heart  Association  is  not  un- 
aware that  the  multiplicity  of  campaigns  creates 
a problem  for  the  community  and  for  the  As- 
sociation itself.  It  reaffirms  its  readiness  to  join 
with  other  comparable  health  groups  in  some 
form  of  “Health  Fund.”  Until  such  plans  ma- 
ture, the  Washington  Heart  Association  must 
finance  its  work  through  the  established  methods 
of  an  annual  campaign  for  funds. 

The  Washington  Heart  Association  will  open 
its  1952  campaign  for  funds  and  “New  Hope  for 
Hearts”  on  February  1,  1952.  The  goal  is  $80,000, 
a comparatively  small  sum  for  this  metropolitan 
area  to  raise  to  combat  the  greatest  cause  of 
death  and  disability  today.  The  goal  is  better 
health  and  longer  lives  for  all  of  us  and  for  our 
children,  something  which  cannot  be  easily  meas- 
ured in  currency. 

Bern.xrd  J.  Walsh,  M.D. 

President,  Washington  Heart  Association,  Inc. 


MODERN  THERAPY;  ACCEPTED  METHODS  OF  TODAY,  TRENDS  FOR 

TOMORROW 


'Fhe  above  title  is  the  central  theme  of  the 
Midwinter  Seminar  to  be  held  in  the  Medical 
Society’s  auditorium  on  Wednesday  and  ddiurs- 
day,  February  20  and  21,  1952. 

Believing  that  the  i)rimary  object  of  the  prac- 
ticing ])hysician  is  and  should  be  to  provide  the 
patient  with  the  best  {)ossible  treatment  for  the 
particular  ailment  from  which  he  suffers,  the 
Society’s  Program  Committee  is  planning  this 
Seminar  to  be  a practical  2-day  study  of  the 
latest  advances  in  all  lines  of  therapy.  Each 
speaker  will  open  his  talk  with  a brief  resume  of 
the  clinical  entity  he  is  discussing  and  will  spend 
the  greater  portion  of  his  talk  outlining  how  this 
disease  should  be  treated.  He  will  close  with  a 
re|)ort  on  current  investigative  work.  Papers  will 


be  limited  to  20  minutes;  an  additional  10  min- 
utes will  be  allotted  each  speaker  for  direct 
questions  from  the  floor.  Moderators  will  main- 
tain rigid  adherence  to  the  time  schedule  and 
will  insist  that  ([uestions  be  brief  and  pertinent 
to  the  topic  under  discussion.  As  wide  a range 
of  subjects  as  possible  will  be  discussed. 

All  of  the  speakers  at  the  Seminar  will  be 
local  physicians,  either  clinicians  actively  en- 
gaged in  the  {practice  of  medicine  or  physicians 
doing  special  investigative  work  in  hospitals. 
Each  speaker  is  being  screened  by  the  Committee 
not  only  for  his  knowledge  of  the  subject  but 
also  for  his  ability  to  present  that  knowledge  to 
an  audience  of  several  hundred  others. 


VOL.  XXI,  NO.  1 


Medical  Annals  of  the  District  of  Columbia 


31 


Many  physicians  do  not  appreciate  the  wealth 
of  excellent  investigative  work  which  is  being 
carried  on  in  our  local  hospitals,  including  not 
only  the  private  institutions  and  the  municipal 
hospital  but  the  service  and  veterans’  hospitals 
as  well.  All  of  this  cannot  be  covered  in  2 days, 
but  much  of  the  more  significant  work  which  is 
ready  for  publication  will  be  presented. 


Thus  the  Committee  feels  it  will  present  a 
Seminar,  by  and  for  Washington  physicians, 
which  will  proudly  take  its  place  alongside  the 
Annual  Scientific  Assembly  as  a medical 
event  of  such  significance  that  every  Washing- 
ton physician  will  feel  that  he  must  attend. 

Darrell  C.  Crain,  M.I). 

Acting  Chairman,  Program  Committee 


THE  ELEVENTH  DAVIDSON  LECTURER 


Dr.  Jonathan  Marshall  Williams  was  selected 
by  the  Davidson  Lecture  Committee  to  present 
the  Eleventh  Davidson  Lecture  on  February  20. 
Usually  the  Davidson  Lecture  is  given  at  one  of 
the  first  scientific  meetings  in  October,  but  this 
year,  with  the  change  in  program  procedure,  the 
Davidson  Lecture  will  be  held  in  connection  with 
the  Midwinter  Seminar.  The  subject  of  the 
address  will  be  “The  Amygdaloid  Nucleus.’’ 

The  Davidson  Lecture  was  established  in 
1929  to  commemorate  the  outstanding  service 
rendered  to  the  medical  profession  by  Dr.  Ed- 
ward Young  Davidson,  who  was  almost  solely 
responsible  for  the  erection  of  the  Medical 
Society’s  “home’’  at  1718  M Street,  N.W.  The 
Lecturer  is  selected  biennially  on  the  basis  of 
competition  by  a subcommittee  of  the  Executive 
Board.  The  award  consists  of  a certificate  and 
the  income  from  the  Davidson  Lecture  Fund, 
an  amount  of  money  subscribed  by  members  of 
the  Society  many  years  ago  to  be  used  for  this 
purpose.  This  year  members  of  the  subcommittee 
which  selected  the  winning  paper  were:  Dr. 
John  Minor,  Chairman;  Drs.  Walter  Freeman, 
William  M.  Ballinger,  Raymond  T.  Holden, 
and  Herbert  P.  Ramsey.  The  Committee  was 
particularly  [)leased  with  Dr.  Williams’  con- 
tribution. 

Dr.  Williams  is  one  of  the  younger  members  of 
the  Medical  .Society  of  the  District  of  Columbia.  He 
holds  a teaching  position  with  (leorge  W ashington 
University  School  of  Medicine  as  Associate  in  Neuro- 
surgery, a i)ost  which  he  has  held  since  1947.  4'he 
year  prior  to  this  aj)pointment  he  was  a member  of 


JON.ATHAN  M.  williams,  M.I). 


the  faculty  of  Loyola  University  School  of  Medicine 
as  Clinical  Instructor  in  Neurosurgery. 

Dr.  Williams  was  born  in  Chicago,  Illinois,  .\ugust 
.10,  1912,  the  son  of  David  Irwin  and  Agnes  Marshall 
W’illiams.  He  was  educated  in  the  public  schools  of 
Evanston,  111.,  and  attended  the  College  of  Wooster 
in  Wooster,  Ohio.  He  received  his  {)reclinic.d  train- 
ing at  Loyola  University  School  of  Medicine,  receiv- 
ing the  degree  of  Bachelor  of  Science  in  Medicine  in 
19.16,  Two  years  later  he  was  granted  his  medical 
degree  from  the  Ifiiiversity  of  Chicago  School  of 
Medicine.  He  interned  at  the  ('ity  Hosi)ital  in  Cleve- 
land, Ohio. 


32 


In  and  Out  of  Focus — Observer 


JANUARY,  1952 


After  his  internship  Dr.  Williams  began  intensive 
study  in  the  field  of  neurosurgery.  He  was  resident 
physician  at  City  Hospital  for  another  year  and 
served  a year’s  residency  at  Gallinger  Municipal 
Hospital,  Washington,  from  1940  to  1941.  From 
1941  to  1942  he  held  a fellowship  in  neurosurgery 
and  neurology  at  George  Washington  University 
Hospital.  With  the  advent  of  World  War  H he 
was  commissioned  in  the  Medical  Corps  of  the  S. 
Xavy,  serving  for  four  years,  1942-1946.  He  was 
separated  with  the  rank  of  Lieutenant  Commander. 
In  recognition  of  his  services  he  was  awarded  the 
Purple  Heart,  two  Navy  Unit  commendations,  and 
the  Asiatic  Medal  with  five  campaign  stars. 

The  first  year  following  his  separation  from  Xaval 
service.  Dr.  Williams  spent  in  Chicago,  Illinois,  in 
association  with  Dr.  Harold  C.  Voris,  their  practice 
limited  to  neurological  surgery.  In  1947  he  moved 
to  Washington,  D.  C.,  where  he  has  carried  on  the 
private  practice  of  his  specialty.  His  office  is  located 
at  2014  R Street,  N.W. 

Dr.  Williams  is  on  the  medical  staff  of  many  of 
the  \\’ashington  hospitals.  He  is  Attending  Neuro- 
surgeon at  George  Washington  University,  Garfield 
Memorial,  Children’s,  and  Gallinger  Hospitals;  staff 
consultant  to  Episcopal  Eye,  Ear,  Nose  and  Throat; 
and  special  consultant  to  Newton  D.  Baker  \"eterans 
Hospital  in  Martinsburg,  West  Virginia.  He  is  a 
diplomate  of  the  American  Board  of  Psychiatry  and 
Neurology,  in  Neurology,  and  of  the  American  Board 
of  X^eurological  Surgery.  / 


An  Active  member  of  the  Medical  Society  of  the 
District  of  Columbia  since  1947,  Dr.  Williams  has 
participated  in  many  committee  activities.  For  the 
22nd  Annual  Scientific  Assembly  of  the  Society 
he  did  an  outstanding  piece  of  work  as  Chairman  of 
the  Scientific  Exhibit;  this  year  he  is  Vice  General 
Chairman  of  the  Committee  on  General  Arrange- 
ments for  the  23rd  Assembly,  and  will  therefore 
become  General  Chairman  in  1953. 

Dr.  Williams  is  a Fellow  of  the  American  Medical 
Association  and  a member  of  the  American  Academy 
of  X’eurology.  He  is  a member  and  Past  Chairman 
of  the  Medical  Society’s  Section  on  X’^eurology  and 
Psychiatry,  and  Chairman  of  the  Medical  Advisory 
Committee  of  the  Washington  Chapter,  United  Cere- 
bral Palsy  Association. 

Already  he  has  to  his  credit  an  impressive  list  of 
papers  which  have  been  published  in  national  and 
state  medical  journals,  including  the  Medical  .An- 
nals OF  THE  District  of  Columbia.  He  prepared 
the  Section  on  XTurology  for  the  third  edition  of 
“.A  Textbook  of  Medicine”  by  Dr.  Wallace  M. 
Abater. 

Dr.  Williams  was  married  to  Miss  Morrell  Lip- 
hart  in  1939.  They  are  the  parents  of  five  children, 
David  AI.,  Stephen  C.,  Meredith  Ann,  Morelle  Eliza- 
beth, and  Deborah  Rose.  The  last  two  are  twins, 
who  accented  Dr.  Williams’  achievement  of  being 
named  the  Davidson  Lecturer  by  being  born  the 
same  day  he  was  notified  of  the  award.  The  family 
resides  at  705  Highland  .Avenue,  X’.W. 


. There  are  few  pastimes  which 
Meatciue  tn  ^ , 

your  Observer  finds  more  enjo}'- 

able  than  firowsing  through  a 
shelf  of  old  books.  He  is  not  one 
of  those  who  can  afford  to  indulge  in  the  luxury 
of  first  editions,  but  that  does  not  dampen  his 
enthusiasm.  He  never  passes  a book  shop  that 
he  is  not  tempted  to  dally  awhile.  To  him,  ad- 
venture beckons  and  it  is  difficult  to  resist. 

A'our  Observer  discovered  quite  by  accident 


Washington 

-1867 


that  old  medical  books  also  hold  a fascination  for 
Dr.  Henry  L.  Darner,  well-known  member  of 
our  Medical  Society.  He  has  a standing  order 
with  booksellers  in  Washington  for  the  type  of 
books  in  which  he  is  interested.  One  evening  at 
dinner,  several  months  ago,  Dr.  Darner  showed 
your  Observer  a modest  little  volume  entitled 
“Medical  Register  of  the  District  of  Columbia, 
1867.”  He  had  just  received  it  from  one  of  his 
“scouts.”  I'humbing  through  its  pages  your  Ob- 


VOL.  XXI,  NO.  1 


Medical  Annals  of  the  District  of  Columbia 


33 


server  noted  some  highly  interesting  historical 
information  which  he  felt  would  be  of  interest 
to  readers  of  the  Medical  Annals.  He  asked  if 
he  might  borrow  the  Register,  a request  which 
was  gladly  granted. 

After  digesting  its  contents  more  thoroughly, 
your  Observer  has  selected  for  publication  por- 
tions which  are  most  revealing  of  the  medical 
life  and  institutions  in  our  community  some  85 
years  ago.  Dr.  J.  M.  Toner,  who  was  to  become 
the  President  of  the  Medical  Society  of  the 
District  of  Columbia  in  1871,  and  who  is  the 
author  of  the  Register,  writes  in  the  preface: 

“The  work,  in  its  general  scope,  is  modeled 
after  the  ‘New  York  Medical  Register,’  and  is 
designed  to  give  information  of  all  Medical  So- 
cieties, Colleges,  Hospitals  and  Infirmaries,  with 
brief  notices  of  our  public  and  private  benevolent 
Institutions,  Libraries,  etc.,  and  the  names  of  the 
officers  and  physicians  in  charge. 

“It  is  believed  that  a work  supplying  this 
information,  with  the  modes  of  admission  to  the 
different  institutions  of  charity,  will  be  useful  to 
! the  profession  and  the  public  generally.” 

There  follows  a monthly  medical  calendar  of 
events.  Reproduced  in  the  next  column  is  the 
calendar  for  January,  1867. 

I It  will  be  observed  that  the  calendar  was  a 
i catch-all,  all  sorts  of  meetings  and  anniversaries 
; being  noted. 

1 Included  in  the  “Register”  are  a number  of 
organizations  and  institutions  which  Dr.  Toner 
describes  in  more  or  less  detail.  Here  are  some 
excerpts: 

I 

!clmcrican  iWciJical  dissociation 

“The  Association  is  composed  of  permanent  members 
and  delegates  from  regularly  organized  Medical  Societies, 
Medical  Colleges,  Hospitals,  Lunatic  Asylums,  and  other 
permanently  organized  medical  institutions  of  good 
standing  in  the  United  States,  and  from  the  American 
Medical  Society  of  Paris.  A Delegate,  after  serving  one 
year,  becomes  a permanent  member.  Kach  local  society 
has  the  privilege  of  sending  one  delegate  for  every  ten 
of  its  regular  resident  members,  and  one  for  every  fraction 
of  more  than  half  this  number.  The  faculty  of  every 
Medical  College  and  chartered  school  have  the  privilege 


MEDICAL  REGISTER. 


1 

1867. 

JANUARY.  1st  Month. 

w 

^ o 
fi  a 

' • 

o (4 

iH  W 

Q P 

Chronology,  Chnrch  Fcs'ivals,  and  Days  of  Meet- 
ing of  Medical  Societies  in  Washington,  D.  C. 

1 

Tues. 

Circumcisio  Domini.  First  Convention  to  form 
National  Pharmacopia  met  in  Washington,  1820. 

2 

Wed. 

Med. Soc.,D.C., meets.  Georgia adop.  Fed.  con. 1788. 

3 

Thu. 

Bat.  of  Princeton,  1777.  Gen.  Hull's  trial  com . 1814. 

4 

Fri. 

N.  Y.  and  other  States  protest  against  seces'n,  1861. 
Clin.  Path.  S.  meets.  Star  of  the  West  sailed  to 
reinforce  Fort  Sumter,  1861. 

6 

Sat. 

6 

Sun. 

Fort  Washington,  on  the  Potomac,  reinforced,  1861. 

7 

Mon. 

Stated  Yearly  Sleeting  of  the  Med.  Soc.,  D.  C. 
Thompson,  Sec’y,  resigned.  Miss,  seceded,  1861. 

8 

Tues. 

9 

Wed. 

Sled.  Soc.,  D.  C.,  meets.  Conn.  adop.  Fed.  con. 1788. 

10 

Thu. 

Polk  and  Johnson,  of  Mo.,exp’d  from  U.S.  Sen. 1862. 

11 

Fri. 

Library  Com’y  of  Alexandria,  Va.,  chartered,  1798. 

Alabama  and  Florida  seceded,  1861. 

12 

Sat. 

Clin.  Path.  S.  Remarkable  eclipse  of  the  Sun,  1831. 

13 

Sun. 

Cameron  res’d  as  Sec  of  War,  and  Stanton  app.  1862 

14 

Mon. 

C.S.  Alabama  sunk  armed  trans.  off  Galveston, 1862 

15 

Tues. 

Col.  Hayne,  Com’r  from  S.  C.  demands  evacuation 
of  Fort  Sumter,  1661. 

10 

Wed. 

Med.  Soc.,  D.  C.,  meets.  Florida  prohibits  expor- 
tation of  provisions,  1862. 

17 

Thu. 

Nav.  of  Mies,  closed  by  ice  below  St.  Louis,  1862. 

18 

Fri. 

Great  conflagration  in  Alexandria,  Va.,  1827. 

19 

Sat. 

Clin.  Path.  S.  Antarctic  continent  discovered  by 
U.  S,  Exp.  Expedition,  1840.  Georgia  sec’d,  1861. 

1 20 

Sun. 

Georgetown  Col.  chart,  by  Gen.  Assem.  of  Md.  1798. 

i 21 

Mon. 

Negroes  at  Port  Royal,  S.  C.,  fum’d  with  arms, 1861 

22 

Tues. 

Sherrard  Clemens,  Va.  made  strong  Union  speech 
in  Congress,  1861. 

1 23 

Wed. 

Med.Soc.,D.C.  meets.  Dr.F.May,  of  Wa8h.died,1847 

24 

Thu. 

U.  S.  Arsenal  at  Augusta.  Ga.,  surrendered  to  the  1 
Governor  of  the  Slate,  1861.  | 

25 

Fri. 

Insurgents  under  Shay,  in  Mass.,  defeated,  1787.  ' 

26 

Sat.  j 

Clin.  Path.  S.  meets.  Michigan  admitted  into  1 
Union,  1837.  Louisiana  seceded,  1861.  j 

27 

Sun. 

Aaron  Burr  arrested  for  conspiracy,  1807.  1 

28 

Mon.  ' 

Amer.  Hist.  Soc.  formed  in  Washington,  1835.  j 

29 

Tues. 

Kansas  admitted  into  the  Union,  1861. 

30 

Wed.  j 

Med.  Soc.  D.  C.  meets.  Iron  plated  steam  battery 
Monitor  launched  at  Greeupoint,  L.  I.,  1862.  | 

31 

Thu.  j 

Wash.  Nat.  Monument  Society  incorporated,  1848.  '• 

1 

i 

of  sending  two  delegates.  The  professional  staff  of  every 
chartered  or  municipal  hospital  containing  a hundred 
inmates  or  more  have  the  privilege  of  sending  two  dele- 
gates and  every  other  medical  institution  of  good  standing 
has  the  privilege  of  sending  one  delegate. 

* * * ♦ 

“The  profession  of  the  District  of  Columbia  is  entitled 
under  the  regulation  of  the  Association  to  representation 
from  the  following  institutions; 

The  Medical  Society  of  the  District  of  Columbia. 

The  Medical  Association  of  the  District  of  Columl)ia. 

The  Clinico-Pathological  Society  of  the  District  of 
Columbia. 

The  National  Medical  College. 

The  Medical  Department  of  Georgetown  College. 

'I'he  Government  Hospital  for  the  Insane. 

'Phe  Columbia  Hospital  for  Women,  and  Lying-in 
.Asylum. 

Providence  Hospital. 


34 


In  and  Out  oj  Focus — Observer 


JANUARY,  l‘>52 


W ashington  Asylum. 

“The  Medical  Corps  of  the  Army  and  Navy  of  the 
United  States  are  each  entitled  to  representation  in  this 
Association,  and  usually  send  two  delegates  each.” 

Jtlebical  ^ocictp  of  tljc  of  Columbia 

“This  Society  was  organized  on  the  26th  September, 
1817.  Subsequently  a charter  was  obtained  from  Con- 
gress, which  received  the  approval  of  the  President  of 
the  United  States  on  the  16th  February,  1819.  The 
charter  gave  to  the  Society  the  authority  to  examine 
and  license  duly  qualified  Physicians  to  practice  medi- 
cine within  the  District  of  Columbia. 

“'Fhe  Society  is  composed  of  honorary  and  resident 
members,  and  fellows.  Its  object  is  to  ‘grant  licenses 
agreeably  to  the  charter,  and  the  consideration  and  pro- 
motion of  all  subjects  connected  with  medicine,  and  the 
collateral  branches  of  the  science.’  ” 


CIinico=^atf)ological  ^otietp  of  Uist.  of  Columbia 

“This  association  was  formed  in  May,  1865,  by  the 
junior  practitioners  of  the  city.  The  chief  object  of  the 
Societ}-,  as  expressed  in  its  by-laws,  is  for  ‘mutual  im- 
prov’ement  in  diagnosis  and  clinical  observation.’ 

“It  was  originally  organized  with  a corps  of  active 
members,  limited  to  twelve.  The  number  has  since  been 
increased  to  sixteen.  Each  active  member  is  required  by 
the  constitution  and  by-laws  to  present  a medical  or 
surgical  case,  or  essay,  for  the  consideration  of  the 
Society,  in  the  order  in  which  his  name  appears  in  the 
alphabetical  list  of  members.  There  is  no  limit  to  the 
number  of  honorary  members,  but  so  far  a few  only 
have  been  chosen.” 

* * * 

Dr.  II.  P.  Middleton President 

Dr.  S.  J.  Todd Secretary 


* * ♦ 

BOARD  OF  EXAMINERS 

J.  M.  T oner,  M.D.  S.  A.  H.  McKim,  M.D* 

J.  F.  Thompson,  M.D.  Johnson  Eliot,  M.D. 

James  E.  Morgan,  M.D. 

Jllcbical  Slgsociation  of  tbc  IBigtrict  of  Columbia* 


ACTIVE  MEMBERS 


Dr.  W'ni.  B.  Drinkard 
Dr.  C.  M.  Ford 
Dr.  .4.  F.  King 
Dr.  William  Lee 
Dr.  II.  P.  Middleton 
Dr.  D.  W.  Prentiss 


Dr.  H.  .A.  Robbins 
Dr.  Wm.  E.  Roberts 
Dr.  J.  F.  Thompson 
Dr.  S.  J.  Todd 
Dr.  James  T.  Young 


“The  object  of  the  Association  is  the  elevation  of  the 
profession,  the  establishment  of  a code  of  ethics  and  a 
fee  bill,  and  the  promotion  of  harmony  and  good  fellow- 
ship among  its  members. 

* « * 

“.-Vpidications  for  membership  are  made  by  letter  to 
the  Secretary,  who  will  lay  the  application  before  the 
.Association  at  its  next  meeting.  If  the  applicant  be  a 
member  of  the  Medical  Society  of  the  District  of  Colum- 
bia, and  duly  qualified,  he  will  be  at  once  balloted  for, 
and  upon  receiving  two-thirds  of  the  votes  cast,  will  be 
declared  a member,  on  signing  the  regulations  and  code 
of  ethics,  rhese  are  the  same  in  principle  as  those  of  the 
.American  Medical  Association.” 

OFFICERS  OF  THE  ASSOCIATION 


Joshua  Riley,  M.D President 

Joseph  Borrows,  M.D A'ice-President 

J.  W.  H.  L ovejoy , M.D Secretary 

J.  M.  Toner,  M.D Treasurer 


* The  Medical  .Association  of  the  District  of  Columbia  was 
amalgamated  with  the  Medical  Society  of  the  District  of  Co- 
lumbia in  1911,  the  latter  taking  over  the  activities  of  the 
lormer. 


HONORARY  MEMBERS 


Dr.  W.  P.  Johnston Washington 

Dr.  James  C.  Hall  W ashington 

Dr.  C.  H.  Liebermann .Washington 

Dr.  F.  J.  Bumstead New  York 


(£5corgetobm  College 

“This  institution  is  owned  by  the  Society  of  Jesus, 
and  was  chartered  by  the  General  .Assembly  of  Maryland 
in  1798.  In  1815  Congress  amended  the  charter,  and 
granted  them  all  the  privileges  of  a university.  The 
order  has  erected  large  and  imposing  college  edifices  on  a 
beautiful  and  commanding  site,  overlooking  the  city  of 
Washington  and  the  Potomac  river,  and  a large  district 
of  Ahrginia.  .Adjacent  to  the  College  on  an  eminence 
stands  their  Observatory,  where  they  hav'e  first-class 
astronomical  apparatus. 

“Surrounding  the  College  is  a large  enclosure,  part 
of  which  is  laid  off  in  tasteful  walks  and  plav’-grounds, 
and  the  remainder  is  cultivated  as  a garden  and  vineyard. 
.Although  the  organization  of  the  College  is  Catholic, 
youths  of  other  denominations  are  received  and  placed 
on  an  equality  of  privileges  and  advantages  with  those 
of  their  own  faith. 


VOL.  XXI,  NO.  1 


Medical  Annals  of  the  District  of  Columbia 


35 


“I'he  average  annual  number  of  students  at  this  Col- 
lege is  about  225. 

“The  course  of  classics  and  mathematics  taught  in  this 
institution  is  scarcely  equalled  by  any  other  College  in 
the  country.  Studies  were  partially  interrupted  in  the 
College  during  the  war,  in  consequence  of  one  of  the 
buildings  being  used  as  a hospital.  They  are  now  re- 
occupied by  the  College,  at  which  there  is  a large  class 
of  students  assembled  from  all  parts  of  the  country. 

* * * 

“The  following  are  the  names  of  the  chief  oflicers  of 
the  College: 

Rev.  Bernard  A.  Maguire,  S.  J.,  President 
Rev.  Edmund  J.  Young,  S.  J.,  \dce  President 
Grafton  Tyler,  M.D.,  Physician 
* * * 

“The  eighteenth  annual  lecture  term  of  1867-68  will 
commence  on  the  10th  October  next,  and  terminate  in 
March. 

“The  following  is  the  Faculty  of  Medicine: 

Noble  Young,  M.D.,  President,  Professor  of  Principles 
and  Practice  of  Medicine. 

P'lodoardo  Howard,  M.D.,  Treasurer,  Professor  of  Ob- 
stetrics and  Diseases  of  Women  and  Children. 

Johnson  Eliot,  M.D.,  Dean,  Professor  of  Principles  and 
Practice  of  Surgery. 

James  E.  Morgan,  i\ED.,  Professor  of  Materia  Medica 
and  Therapeutics. 

Thomas  .\ntisell,  M.D.,  I’rofessor  of  Alilitary  Surgery, 
Physiology,  and  Physiological  Chemistry. 
Montgomery  Johns,  M.D.,  Professor  of  General,  Micro- 
scopic and  Descriptive  .\natomy. 

Silas  L.  Loomis,  AI.D.,  Professor  of  General  Chemistry 
and  Toxicology. 

J.  H.  Thompson,  M.D.,  Professor  of  Surgical  Diseases 
of  Women. 

D.  H.  Hagner,  M.D.,  Professor  of  Clinical  Medicine. 

W.  Evans,  M.D.,  Demonstrator  of  Anatomy. 


“The  fees  for  the  full  Course  of  Lectures  8105.00 

Matriculation  fee  (paid  only  once) 5 .00 

Demonstrator’s  fee 10.00 

Graduation  fee 10.00 


“Students  are  not  compelled  to  take  all  the  tickets 
during  one  session.  Fee  for  single  ticket  815.” 

Columbian  College 

(now  George  Washington  University) 

“This  institution  was  established  by  the  liberality  of 
the  flenomination  of  Baptists  in  1819,  and  chartered  by 
Congress,  with  the  privileges  of  a University,  February 
9,  1821.  One  of  the  most  beautiful  sites  in  the  District 


of  Columl)ia  was  selected  for  the  College,  commanding  a 
view  of  IVashington,  Georgetown  and  Alexandria.  The 
buildings  of  the  institution  are  large,  substantial,  and 
tasteful.  The  extensive  grounds  of  the  College  have  re- 
cently been  improved  by  the  laying  out  of  walks,  the 
planting  of  fruit  and  shade  trees,  and  the  erection  of  a 
stone  wall  along  the  Fourteenth-street  road,  Src.,  &c. 
.A  donation  by  Congress  to  this  institution,  in  1854,  of 
vacant  lots  in  the  city  of  Washington,  valued  at  825, ()()(), 
greatly  assisted  the  trustees  in  the  enterprise. 

“The  College  under  its  present  able  management,  is 
well  sustained,  and,  from  the  number  of  its  students, 
may  be  considered  as  in  a flourishing  condition.  There  are 
155  stuflents  in  the  academic  department. 

* * * 

“The  following  are  the  chief  oflicers  of  the  institution: 
Rev.  George  W.  .Samson,  D.D.,  President  of  the  h'aculty. 
Col.  James  L.  Edwards,  President  of  the  Board  of 
'I'rustees. 

William  Ruggles,  LL.D.,  and  other  able  Professors. 

* * * 

“The  Meflical  Department  of  the  College  was  or- 
ganized, anfl  lectures  commenced,  March  50,  1825.  The 
first  class  graduated  in  1826.  With  slight  interruptions, 
medical  lectures  have  been  annually  delivered  ever  since 
to  good  classes,  by  able  Professors. 

“The  Medical  Faculty,  some  years  ago,  adopted  the 
present  name,  ‘National  Medical  College,’  but  the  degree 
of  M.D.  is  granted  under  the  authority  of  the  charter  of 
Columbian  College. 

“Recently  W.  W.  Corcoran  gave  to  the  'I'rustees  of 
Columbian  College  a handsome  building  on  H Street, 
between  I'hirteenth  and  Fourteenth  streets,  for  the  use 
of  the  Medical  Department  of  the  College,  where  a course 
of  lectures  is  now  being  delivered  to  a class  of  about 
twenty-five  students. 

“'I'he  following  is  the  Faculty  of  the  National  Medical 
College: 

'I'homas  Miller,  M.D.,  Emeritus  Professor  of  .Anatomy 
and  Physiology,  and  President  of  the  Faculty. 
William  P.  Johnston,  M.D.,  Professor  of  Obstetrics  and 
Diseases  of  Women  and  Children. 

John  C.  Riley,  M.D.,  Professor  of  Materia  Mcdica  and 
'I'herapeutics. 

Nathan  Smith  Lincohi,  M.D.,  Professor  of  Special, 
()j)erative,  and  Clinical  Surgery. 

George  C.  Schaeffer,  M.D.,  Professor  of  Chemistry. 
George  M.  Dove,  M.D.,  Professor  of  the  'I'heory  and 
Practice  of  Medicine. 

John  Ordronaux,  M.D.,  Professor  of  I’hysiology,  Pa- 
thology, and  .Medical  Jurisprudence. 


JANUARY  1952 


In  and  Out  of  Focus — Observer 


36 

Thomas  R.  Crosby,  M.l).,  Professor  of  General  and 
Military  Surgery  and  Hygiene. 

J.  P'ord  Thompson,  M.D.,  Professor  of  Anatomy. 

A.  V.  P.  Garnett,  M.U.,  Professor  of  Clinical  Medicine. 
William  B.  Drinkard,  M.D.,  Demonstrator  of  .\natomy. 
Trederich  Shafhirt,  M.D.,  Curator  of  Museum. 

“The  lectures  commence  on  Monday,  15th  October. 
The  entire  expense  for  a full  course  of  lectures 


by  all  the  Professors  is Si 05. 00 

Single  tickets 15.00 

Practical  Anatomy,  by  the  Demonstrator  10.00 

Matriculating  fee,  payable  only  once  5.00 

Graduating  expenses 30.00 

No  charge  made  for  clinical  lectures.” 


'Phese  are  merely  samples  of  the  highly  inter- 
esting historical  data  contained  in  the  Register. 
Illustrative  of  the  diversification  and  the  extent 
of  additional  information  it  contains  are  the 
following  headings:  American  Pharmaceutical 
.Association,  Pharmaceutical  Association  of 
Washington,  Providence  Hospital,  Columbia 
Hospital  for  Women,  and  Lying-In  .Asylum, 
Covernment  Hospital  for  the  Insane,  Surgeon 
(ienerals  of  the  U.  S.  .Army,  .Army  Medical 
Museum,  Subdivision  of  Vital  Statistics,  List  of 
Medical  Officers  of  the  U.  S.  .Army  on  Duty  in 
Washington  City,  Jan.  1,  1867,  Military  .Asylum, 
Washington  City  Post  Hospital,  Kalorama  Hos- 
pital, Bureau  of  Medicine  and  Surgery  of  the 
U.  S.  Navy,  Naval  Hospital,  Freedmen’s  Hospi- 
tal, Washington  City  Orphan  Asylum,  St.  Vin- 
cent’s Female  Orphan  .Asylum,  St.  Joseph’s  Male 
Orphan  Asylum,  St.  .Ann’s  Infant  Asylum,  Na- 
tional Association  for  the  Relief  of  Destitute 
Colored  Women  and  Children,  National  Soldiers’ 
and  Sailors’  Orphan  Home,  Washington  City 
Government,  Washington  .Asylum,  Washington 
Small  Pox  Hosjiital,  Ward  Physicians  for  the 
Poor,  Ward  Apothecaries  for  the  Poor,  Board 
of  Health,  Georgetown,  1).  C.,  and  Georgetown- 
Ward  Physicians. 

Following  the  above  are  names  of  qualified 
medical  practitioners,  apothecaries  and  druggists 
in  the  District. 

This  is  by  no  means  a complete  list  of  the 
subjects  dealt  with,  for  the  author  takes  it  for 
granted  that  the  interest  of  his  readers  will  in- 
dude  such  topics  as  Laying  the  Cornerstone  of 


the  Capitol  of  the  United  States,  Biographical 
Sketches  of  Senators,  and  the  Smithsonian  Insti- 
tution. 

ATur  Observer  was  astonished  at  the  amount 
of  information  Dr.  Toner  found  possible  to  in- 
corporate in  such  a modest  volume.  Washington 
physicians  who  like  making  journeys  into  yester- 
day should  prevail  upon  Dr.  Darner  to  permit 
them  to  peruse,  if  not  to  borrow,  the  Register. 

★ 

Bernard  Devoto,  mainstay  of 
County  Fair?  the  editorial  staff  of  Harper's 
Magazine  has,  on  occasion,  been 
caustic  in  his  criticism  of  the  .American  Medical 
.Association.  Much  of  it  has  galled  your  Observer 
who,  if  he  were  in  the  position  to  do  so  effectively, 
would  have  taken  issue  with  the  belligerent  Mr. 
Devoto.  In  fairness  to  Mr.  Devoto,  however,  it 
must  be  admitted  that  he  has  not  been  wrong 
on  all  counts.  There  are  vulnerable  spots  in  the 
armor  of  any  organization  and  that  is  true  of  the 
.American  Medical  .Association. 

In  an  article  which  appeared  in  Harper's  some 
two  or  three  years  ago  VIr.  Devoto  described  the 
.American  Medical  .Association  meeting  at  .At- 
lantic City  in  more  or  less  acid  language.  His 
sharpest  barbs  were  directed  at  the  technical 
or  commercial  exhibits.  He  described  the  at- 
mosphere in  those  exhibits  as  that  of  a “county 
fair.”  Your  Observer  squirmed  a bit  at  that  one, 
for  the  term,  in  his  opinion,  was  too  accurate 
for  comfort. 

Early  last  year  a mimeographed  copy  of  an 
address  came  across  your  Observer’s  desk  en- 
titled “Medical  Conventions-County  Fair — Or” 
by  S.  M.  Fossel,  .Assistant  Vlanager  of  Sandoz 
Pharmaceuticals,  given  before  the  .American 
Pharmaceutical  Manufacturers’  .Association  on 
January  29,  1951.  Certainly  no  one  could  charge 
Mr.  Fossel  with  being  unfriendly  to  the  .AAI.A, 
but  his  conclusions  coincided  surprisingly  with 
those  of  Mr.  Devoto  where  technical  exhibits 
were  concerned. 

Here  are  some  of  the  view^s  expressed  by  Air. 
Fossel: 


VOL.  XXI,  NO.  1 


Medical  Annals  of  the  District  of  Columbia 


37 


“I  am  sure  that  the  real  purpose  of  any  worthwhile 
physician  in  attending  a medical  convention  is  to  gain 
scientific  knowledge.  I am  very  much  in  doubt  as  to 
whether  the  direction  we  are  taking  with  medical  ex- 
hibits is  leading  toward  this  goal.  Certainly  the  use  of  a 
brightly  lighted  exhibit,  beautiful  from  the  standpoint 
of  design  and  art,  is  not  contributory.  The  increased 
use  of  samples  and  souvenirs  is  not  contributory.  The 
attendance  of  exhibitors  who  play  no  real  part  in  the 
medical  field  is  no  great  contribution.  With  the  trend  as 
it  is  today,  toward  accepting  almost  all  types  of  ex- 
hibitors, I am  sure  that  within  a matter  of  months  some 
of  us  will  be  having  the  Hadacol  people  and  perhaps  that 
long  sought-after  parrot  in  the  next  booth  to  us.  This  is 
something  that  none  of  us  want. 

“Therefore,  the  first  point  I want  to  make  is  that  in 
our  opinion  medical  conventions  should  be  limited  to 
companies  that  are  directly  related  to  the  medical  pro- 
fession and  have  something  of  a scientific  nature  to  pre- 
sent, in  the  way  of  pharmaceuticals,  medical  books,  etc. 

“Then,  we  face  another  problem  in  medical  conven- 
tions. It  is  one  which  is  not  entirely  in  our  hands.  I 
believe  this  problem,  however,  is  in  part  our  responsi- 
bility because  of  the  type  of  conventions  we  have.  If  we 
did  not  have  an  air  of  ‘county  fair’  about  our  medical 
convention  technical  exhibits,  I do  not  believe  this 
problem  would  exist.  Who  should  be  permitted  to  attend 
medical  conventions?  We  believe  these  meetings  should 
be  limited  to  physicians,  internes  and  residents.  However, 
with  free  souv'enirs  and  exhibitors  who  are  not  related  to 
the  medical  field,  this  section  of  the  meeting  has  become 
very  popular  with  the  doctor’s  family,  his  children, 
friends  and  many  groups  who  would  not  spend  one  minute 
at  a scientific  exhibit.  Perhaps  if  we  present  exhibits 
which  really  contribute  to  the  medical  meetings,  we 
will  not  have  to  take  this  problem  up  with  the  physician 
groups  in  control  of  these  meetings. 

“Earlier,  I stated  that  it  was  my  opinion  that  phj^si- 
cians  attend  medical  conventions  to  obtain  scientific 
information.  We  recently  had  the  fine  cooperation  of 
Research  Society,  Inc.  in  conducting  a survey  on  prob- 
lems related  to  medical  conventions.  Mr.  William  T. 
Doyle,  President,  has  furnished  us  with  the  following 
data. 

“f)ne  of  the  questions  we  askeri  was,  ‘Do  you  attend 
medical  conventions  to  secure  scientific  information?’ 
The  answer  was  unanimous.  One  hundred  per  cent  of  all 
physicians  replying  stated  that  they  did  attend  medical 
conventions  to  secure  scientific  information. 

“We  asked  another  question  which  will  lead  into  tlie 
most  important  point  we  have  to  fliscuss  regarding 
conventions.  'Phe  question  was,  ‘Would  you  like  to  have 
the  research  dei)artment  of  pharmaceutical  manufac- 
turers present  scientific  exhibits  of  the  type  now  seen 
in  the  physicians’  scientific  exhibit  section  at  medical 


meetings?’  Ninety-eight  per  cent  said,  ‘Yes,  we  want 
scientific  exhibits.’ 

“In  this  we  undoubtedly  have  the  answer  to  what  the 
physician  expects  of  us  and  we  have  an  opportunity  to 
develop  an  entirely  different  type  of  program  for  tech- 
nical exhibits. 

“We  also  asked,  ‘Do  you  think  the  exhibitors  who  have 
no  relationship  to  the  medical  profession  should  ex- 
hibit?’ Seventy-five  per  cent  said,  ‘No,  they  should  not.’ 

“.Another  interesting  question  and  one  that  should 
be  very  convincing  to  all  of  us  was:  ‘Would  you  spend 
more  time  at  exhibits  if  they  were  scientific  and  you  were 
permitted  to  stay  without  interruption  unless  you  de- 
sired to  ask  questions  of  technically  trained  personnel?’ 
Eighty-nine  per  cent  stated  that  they  would  spend  more 
time  if  we  would  contribute  scientific  exhibits. 

* * * 

“W’e  must  do  something  about  medical  conventions. 
We  must  pay  the  doctor  for  his  time  and  make  it  well 
worth  while  for  him  to  visit  our  exhibits.  It  is  important 
that  our  e.xhibits  aid  the  physician  in  giving  better  treat- 
ment to  the  patients  waiting  for  him  in  his  office  when 
he  returns  home.” 

Your  Observer  would  be  the  last  to  dispute 
most  of  the  views  e.xpressed  by  Mr.  Fossel.  To 
a large  extent  they  coincide  with  his  own.  How- 
ever, there  is  one  point  on  which  he  is  not  in 
full  agreement- - that  is,  that  only  physicians, 
interns  and  residents  should  be  admitted  to 
medical  conventions.  He  believes  that  junio- 
and  senior  medical  students  especially  are  sufr 
ficiently  advanced  in  their  medical  studies  to 
benefit  from  seeing  the  technical  exhibits.  In 
the  long  run,  commercial  firms  would  also  ben- 
efit by  their  attendance.  Where  the  doctor’s 
family,  children  and  friends  are  concerned,  if 
the  changes  suggested  by  Mr.  h'ossel  become  a 
reality,  their  interest  in  technical  exhibits  will 
soon  diminish  to  a point  where  it  would  be  no 
problem. 

It  is  safe  to  j)redict  that  it  will  be  some  time 
before  the  ideas  es[)oused  by  Mr.  I''os.sel  will  be 
reali/xvl.  In  the  meantime,  your  Observer  would 
very  much  like  to  know  how  many  officers  of 
state  medical  societies  have  expressed  their  agree- 
ment or  disagreement  with  Mr.  k'ossel.  'I'his 
should  be  indicative  of  what  the  future  holds 
for  technical  exhibits. 


In  and  Out  of  Focus — Observer 


JANUARY,  1952 


Editorials 
on  Politics 


Medical  editors  and  business 
managers  who  gathered  in  Chi- 
cago on  November  12  and  13, 
1951,  for  the  State  Medical  Journal  Conference 
were  well  rewarded.  All  aspects  of  editing  and 
business  administration  of  state  journals  were 
discussed  by  individuals  of  wide  experience.  Your 
Observer,  who  was  moderator  of  a session  de- 
voted to  the  literary  aspects  and  the  mechanical 
make-up  of  medical  journals,  came  away  with 
the  feeling  that  the  time  he  had  devoted  to  the 
(inference  had  been  well  spent.  That  has  not 
always  been  his  e.xperience  at  meetings  of  a 
similar  type. 

In  reflecting  upon  what  he  had  heard  at  the 
C'onference  he  remembered  something  he  thought 
would  be  of  interest  to  his  readers.  He  recalled 
a question,  put  to  a physician-member  partici- 
pant in  a panel  discussion,  on  the  job  of  an 
editor.  This  physician,  who  is  editor  of  one  of 
the  state  medical  journals  south  of  the  Mason- 
Dixon  line,  was  asked  if  he  thought  politics  was 
a proper  subject  for  editorial  comment  in  medi- 
cal journals.  He  thought  not,  in  fact  he  deemed 
it  highly  imj)roper.  Others,  including  Dr.  Wallace 
M.  Vater,  Editor  of  the  Medical  Annals,  took 
issue  with  him.  They  agreed  that  if  “politics” 
was  inteqireted  to  mean  supporting  a sjiecific 
candidate  for  office,  they,  too,  would  not  favor 
editorials  on  politics.  If,  however,  the  broader 
issues  which  affect  medicine  was  meant,  that 
was  “a  hor.se  of  a different  color.”  After  all,  they 
said,  jihysicians  are  also  citizens,  and  in  common 
with  other  citizens  they  are  responsible  for  their 
country’s  welfare.  This  is  equally  true  of  medical 
organizations,  where  health  is  concerned.  When, 
in  their  opinion,  the  Government’s  policies  jeop- 
ardize the  (juality  of  medical  service,  there  is 
no  reason  why  this  fact  should  not  be  considered 
and  commented  on  editorially  in  their  official 
publications. 

Your  Observer  gained  the  impression  that  a 
majority  of  those  present  agreed  with  the  latter 
view.  However,  several  stressed  the  point  that 
an  editor  should  not  deviate  from  the  policies  of 


his  medical  society  in  discussing  political  issues. 
But  there  were  those  who  dissented  and  thought 
that  the  editor  should  be  given  a free  hand. 

Your  Observer  concurs  with  the  point  of  view 
expressed  by  Dr.  Yater  and  others  who  thought 
as  he  did.  He  would  amplify  these  views  as 
follows: 

1 . It  would  be  unrealistic  to  eliminate  political 
editorials  from  state  medical  journals.  After  all, 
these  journals  are  not  only  scientific  publications 
but  “house  organs,”  devoted  to  organizational 
and  other  matters  of  a general  nature. 

2.  Medical  editors  are  too  prone  to  give  a 
one-sided  picture  of  political  firoblems.  More  ob- 
jectivity would  be  highly  desirable.  The  contro- 
versial medical  issues  are  of  far  too  great  impor- 
tance to  the  people  and  the  profession  to  be 
dealt  with  in  an  emotional  and  highly  prejudicial 
manner.  This  is  not  to  suggest  that  many  editors 
do  not  write  objective  editorials,  for  they  do,  but 
there  are  still  too  many  who  adhere  so  closely  to 
the  “party  line”  that  they  merely  parrot  what 
they  consider  to  be  official  views. 

3.  Medical  editors  should  be  given  some  lati- 
tude in  expressing  opinions  on  political  problems 
relating  to  health.  In  other  words,  they  should 
not  feel  that  they  must  avoid  expressing  views 
at  variance  with  their  organizations’  policies.  As 
previously  stated,  readers  are  entitled  to  an  ob- 
jective evaluation  of  these  problems. 

4.  State  medical  journals  should  certainly  not 
be  a forum  for  the  discussion  of  partisan  politics. 
Anyone  qualified  for  editorship  of  such  a journal 
should  realize  without  having  to  be  reminded 
that  the  medical  society  which  he  represents  in- 
cludes all  political  persuasions.  To  forget  this  is 
to  invite  disunity  among  members  and  headaches 
for  the  editor. 

5.  One  cannot  emphasize  too  strongly  the  im- 
portance of  sound  and  well  thought  out  jiolitical 
editorials.  .\lso  there  is  a need  for  more  forth- 
right and  lively  comments  on  politics  in  our 
medical  journals.  Unless  these  qualities  are  pres- 
ent the  time  and  effort  devoted  to  them  are 
wasted,  for  readers  will  pass  them  by. 


VOL.  XXI,  NO.  1 


Medical  Annals  of  the  District  of  Columbia 


39 


_ 1 here  was  never  a time  when 

The  Doctor  , . . 

T u physicians  were  held  in  higher 

Is  Human  ' ^ 

esteem  professionally  than  at 

present.  This  may  be  disputed  by  some,  but 
an  objective  e.xamination  of  the  situation,  your 
Observer  believes,  bears  this  out.  Lest  he  be 
misunderstood  your  Observer  hastens  to  direct 
attention  to  his  use  of  the  words  “esteem”  and 
“professionally.”  There  are  still  many  physicians 
who,  like  the  old  family  doctor,  command  af- 
fection as  well,  but  by  and  large  the  public 
stands  in  awe  of  the  modern  doctor  because  of 
his  scientific  knowledge.  In  other  words,  he  is 
looked  upon  by  many  people  as  a kind  of  super- 
man. 

Reasons  for  this  are  not  difficult  to  find. 
Among  them  are  the  widespread  publicity  given 
the  so-called  wonder  drugs  and  the  “miraculous 
cures”  described  with  increasing  frecjuency  in 
the  magazines  and  newspapers.  Emphasis  on 
early  diagnosis  and  disease  prevention  has  also 
been  a contributing  factor. 

These  and  other  less  prominently  publicized 
milestones  in  medical  progress  have  combined  to 
create  the  impression  that  the  doctor  is  a “miracle 
worker.”  In  the  strictest  sense,  of  course,  he  is 
performing  miracles  if  his  performance  is  com- 
pared with  his  predecessor  of  a generation  or 
two  ago.  But  he  is  far  from  infallible  and  would 
be  the  last  to  make  such  a claim.  While  he  has 
learned  a lot,  he  knows  only  too  well  that  there 
are  vast  undiscovered  areas  of  medical  knowl- 
edge. 

Xo  matter  what  therapy  he  administers  or 
preventive  measures  he  adopts  there  is  always 
the  possibility  of  an  unavoidable  failure.  A case 
in  point  is  the  early  diagnosis  of  malignancies. 
Usually  the  doctor  can  prophesy  with  a fair 
degree  of  certainty  that  the  growth  will  not 
recur.  But  even  under  the  most  favorable  cir- 
cumstances he  would  be  brash  to  commit  him- 
self unqualifiedly  as  to  the  prognosis.  Too  often 
there  have  been  unex{)lainable  recurrences. 

It  is  perhai)s  time  that  those  who  write  on 
medical  subjects  for  our  popular  magazines  de- 
glamorize  the  doctor  and  show  him  as  he  is  an 


earnest,  efficient,  and  a highly  successful  worker 
in  the  field  of  medical  science  endeavoring  to 
stay  the  hand  of  the  Grim  Reaper. 

★ 

^ There  has  been  much  to-do  in 

Mortality 

Among  Our  increase 

Elders  number  of  elderly  people. 

More  people,  we  are  told,  are 
living  to  a ripe  old  age  than  at  any  time  in  our 
history.  1 his  has  posed  many  problems.  One  of 
the  most  serious  is  that  of  employment.  Com- 
pulsory retirement,  especially  of  the  group  past 
65  years  of  age,  has  been  a controversial  issue 
largely  because  employers  have  made  few  ex- 
ceptions even  among  those  whose  physical  and 
mental  {lowers  have  not  visibly  deteriorated. 

Ironically,  it  a{ipears  that  except  for  the  high 
mortality  among  the  older  age  group  in  this 
country  the  employment  situation  would  be 
much  more  serious.  This  is  pointed  up  by  the 
Statistical  Bulletin  of  the  Aletropolitan  Life  In- 
surance Company  for  October,  1951,  which  ob- 
serves that  our  mortality  rates  “lag  behind  other 
advanced  nations.” 

'Fhe  Bulletin  lists  the  causes  of  death  and 
comments  thereon  as  follows: 

Accidents. — “Our  accident  record  is  particularly  bad. 
The  death  rate  from  accidental  injuries  at  ages  45  and 
over  is  higher  in  the  United  States  than  in  any  of  the 
other  16  countries  listed  [England  and  Wales,  Scotland, 
Australia,  New  Zealand,  Canada,  Ireland,  South  .Africa, 
Denmark,  Finland,  France,  Italy,  Netherlands,  Norway, 
Portugal,  Sweden,  and  Switzerland];  this  is  true  for 
both  men  and  women.” 

Cardiovascular-renal  diseases. — These  diseases  are  “seri- 
ous among  older  men  in  the  United  States;  only  Australia 
and  New  Zealand  come  even  near  our  level,  while  many 
countries  record  much  lower  rates.  Our  older  women, 
however,  have  average  death  rates  from  cardiovascular- 
renal  diseases.” 

Diabetes. — “This  disease  is  the  one  leading  cause  of 
death  for  which  women  over  45  in  the  United  States  show 
cxcei)tionally  high  rates.  Their  death  rate  from  this  cause 
was  111.6  [)er  100, ()()()  in  1648;  Canada  comes  closest 
with  a rate  of  91.5.  High  diabetes  mortality  may  reflect 
our  intensive  case-finding  activities  and  better  reporting 
of  the  disease  as  a cause  of  death  in  recent  years;  but 
even  granting  this,  the  level  is  still  well  above  that  in 
other  countries.” 


40 


In  and  Out  of  Focus — Observer 


JANUARY,  1952 


A DOCTOR’S  BELL— 1854 


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The  above  statement  for  medical  services  to  an  indigent  patient  was  found 
among  some  old  papers  by  Dr.  R.  Lee  Si)ire  of  the  Medical  Annals’  Editorial 
Board.  It  reveals  that  fees  were,  to  say  the  least,  modest  in  the  1850’s. 


Mortality  rates  due  to  tuberculosis,  pneu- 
monia and  influenza  and  other  important  in- 
fectious diseases  are  average  or  below  average 
as  compared  with  those  of  other  countries.  The 
Bulletin  emphasizes  that  if  it  were  not  for  deaths 
from  accidents  among  both  sexes,  the  cardio- 
vascular-renal diseases  in  men  and  diabetes 
among  women,  “the  United  States  would  rank 
very  favorably  among  the  countries  of  the  world 
with  respect  to  mortality  at  the  older  ages  as 
well  as  in  youth  and  midlife.” 

Here  we  run  into  another  paradox,  for  the 


Bulletin  informs  us  that 
a primary  contributing 
factor  “arises  from  the 
excellent  medical  care 
that  has  long  been  avail- 
able in  the  United  States. 
This  has  made  it  possi- 
ble for  a large  number 
of  people  who  suft'ered 
organic  impairments  as 
a result  of  infections  in 
their  earlier  years  to  sur- 
vive into  old  age.  It  is 
probable,  therefore,  that 
there  is  a greater  pro- 
portion of  persons  with 
more  or  less  serious  dis- 
abilities among  our  elders 
than  among  those  of 
other  countries.  This  in 
itself  would  tend  to  make 
our  mortality  in  old  age 
fairly  high. 

“.■\(lded  to  this,  however, 
is  another  important  factor 
that  predisposes  to  high 
mortality  in  old  age — obes- 
ity. The  I nited  States  has 
long  occupied  an  exception- 
ally favorable  position 
among  the  world’s  coun- 
tries with  respect  to  her  food 
supply.  It  is  not  surprising, 
then,  to  find  that  fully  one 
fifth  of  our  adults  are  over- 
weight. .Vs  shown  elsewhere  in  this  issue,  overweight  is 
definitely  associated  with  high  death  rates — particularly 
from  the  cardiovascular-renal  diseases  and  diabetes. 
Many  people  are  litefally  eating  themselves  to  death,  and 
this  is  reflected  in  our  high  mortality  rates  in  old  age.” 

The  Bulletin  concludes: 

“We  have  many  opportunities  for  lowering  the  mor- 
tality of  our  elders  through  health  education  campaigns, 
safety  programs,  regular  medical  examinations,  and  early 
treatment  of  the  degenerative  conditions.  The  fact  that 
older  people  are  becoming  an  increasingly  large  part  of 
our  population  makes  it  more  urgent  than  ever  t’aat  we 
take  adequate  measures  to  safeguard  their  health.” 

r.  w. 


y^l/Lcdical 


Date 

Society  or  Section 

Program 

Place  and  Time 

January  21 

OSLER 

Paper:  James  E.  Wissler,  M.D. 

Case  Report:  Frank  G.  MacMur- 
RAY,  M.D. 

Host:  Dr.  Marshall  deG. 
Rufifin 

January  22 

*D.  C.  Society  of  Anes- 
thesiologists 

“The  Preoperative  Care  of  the  Surgi- 
cal Patient,”  Ralph  M.  Tovell, 
M.D.,  Hartford,  Conn. 

Medical  Society  Audito- 
rium, 8:00  p.m. 

January  28 

Washington  Medical  and 

Surgical 

Speaker:  Andrew  J.  Welebir,  M.D. 
Case  Report:  .•\.  F.  Castro,  M.FJ. 

Hotel  2400,  6:30  p.m. 

January  30 

*Washington  Gynecolog- 
ical 

Three-year  Report  of  the  Fetal 
Mortality  Committee  at  Garfield 
Memorial  Hospital,”  Caroline 
Jackson,  M.D. 

Medical  Society  Audito- 
rium, 8:30  p.m. 

February  5 

Section  on  Ophthalmol- 
ogy 

“Management  of  the  Complications 
of  Cataract  Glaucoma  Surgery  and 
of  Penetrating  Injuries  of  the  Eye,” 
Alston  Callahan,  M.D.,  Profes- 
sor of  Ophthalmology,  Medical  Col- 
lege of  Alabama 

Kennedy-Warren,  6:00 
p.m. 

February  13 

*Washington  Heart  As- 
sociation 

To  be  announced. 

Medical  Society  Audito- 
rium, 8:30  p.m. 

February  18 

OSLER 

Paper:  Thomas  McP.  Brown,  M.D. 
Case  Report:  Theodore  Winship, 
M.D. 

Host:  Dr.  Charles  W.  Ord- 

man 

February  19 

Clinico-Pathological 

Case  Reports:  Weston  Bruner,  Jr., 
M.D.,  and  Henry  L.  Darner, 
M.D. 

Host : Dr.  Fred  R.  Sander- 
son 

February  20 

*Midwinter  Seminar  of 

Modern  Therapy;  .Accepted  Alethods 

Medical  Society  Audito- 

and  21 

D.  C.  Medical  Society 

of  Today,  Trends  for  Tomorrow; 
also 

'I'he  Davidson  Lecture  by  Jonathan 
M.  Williams,  M.D. 

rium,  2:00-5:00  p.m. 
and  8:00-10:00  p.m. 

February  23 

* Washington  Psychiat- 
ric 

“Some  .Aspects  of  the  Mother-Child 
Relationship,”  Jennie  Waelder- 
Hall,  M.D.,  Bethesda,  Md. 

Medical  Society  .Audi- 
torium, 8:30  p.m. 

February  25 

W’ashington  Medical  and 
Surgical 

“Alanagement  of  Metastatic  Malig- 
nancy from  Breast  Cancer,”  James 
H.  Scully,  M.D. 

Case  Report:  Robert  R.  .Montgom- 
ery, M.D. 

Hotel  2400,  6:30p.m. 

February  28 

* George  Washington 

University  School  of 

M EDICINE 

Kellogg  Lecture:  “Some  .Aspects  of 
.Adrenal  Cortical  Physiology  of 
Interest  to  the  Surgeon,”  John 
Hugh  Mulholland,  M.D.,  Pro- 
fessor of  Surgery,  New  A’ork  Uni- 
versity 

Hall  .A,  School  of  Medi- 
cine, 1335  H Street, 
N.W.,  8:30  {).m. 

March  10 

* George  Washington 

University  School  of 
Medicine 

Kellogg  Lecture:  “Practical  .As- 
pects of  the  Physiological  Problems 
of  the  Fetus  and  .Newborn,”  James 
LeRoy  Wilson,  M.D.,  Professor  of 
I’cdiatrics,  University  of  .Michigan 

Hall  .A,  School  of  Medi- 
cine, 1335  H Street, 
.N.W.,  8:30  i).m. 

Open  meetings 


41 


AN  EDITOR  TALKS  SHOP*t 

WILLIAM  ALAN  RICHARDSON 
Editor,  Medical  Economics 


'I'liey  say  that  no  woman  ever  makes  a fool  out 
of  a man.  She  simply  gives  him  the  incentive  to 
develop  his  natural  inclinations. 

Some  time  ago,  when  asked  by  a newly  apiiointed 
state  medical  journal  editor  how  to  get  more  and 
better  nonscientific  material  for  his  pages,  I almost 
followed  a natural  inclination  myself.  I almost  said, 
“Forget  it!  Concentrate  on  the  scientific  articles  in- 
stead.” 

Fortunately,  our  talk  was  interrupted;  so  I did 
not  get  around  to  answering  his  question  until  we 
met  again  a couple  of  weeks  later.  By  that  time  I’d 
had  a chance  to  give  it  more  thought;  and  I felt 
that  his  aim  to  get  more  and  better  nonscientific 
material  was  less  hopeless  than  I had  first  thought. 

Here  was  a man  who’d  never  been  a state  medical 
journal  editor  before.  But  he  had  good  background 
for  it,  plus  enough  personal  drive  and  ability  not  to 
be  satisfied  to  do  a mediocre  job.  He  had  talked  with 
some  of  the  top  clinicians  in  his  part  of  the  country 
in  order  to  plan  his  approach  to  the  problem  of  get- 
ting the  best  possible  scientific  articles.  Now  he 
wanted  my  opinion  about  the  nonscientific  material. 
Since  much  of  what  I told  him  relates  to  my  assigned 
subject  today.  I’ll  simply  pass  it  on  for  whatever  it’s 
worth.  In  speaking  of  my  editor  friend.  I’ll  call  him 
Ed  for  short,  though  that  is  not  his  real  name. 

My  first  remark,  when  we  really  got  down  to 
cases,  was  an  admission  that  I had  felt  pretty  pessi- 
mistic about  Ed’s  problem  when  he  first  posed  it. 

I felt  that  way  offhand,  I said,  because  I know 
most  state  journal  editors  have  a common  occupa- 
tional complaint:  not  enough  staff  to  produce  the 
nonscientific  copy  they  need;  not  enough  money  to 
buy  it. 

“Well,  what’s  the  matter  with  me?”  Ed  asked. 
“My  assistant  and  I ought  to  be  able  to  turn  out  an 

* Read  before  the  Conference  of  Editors  of  State  Medical 
Journals  at  American  Medical  .\ssociation  Headquarters  in 
Chicago  on  November  13,  1951. 

t Editor’s  Note:  While  Mr.  Richardson  preiiared  this 
talk  especially  for  a meeting  of  state  medical  journal  editors, 
it  made  such  livel}'  reading  and  contained  so  many  practical 
suggestions  for  [ihysicians  who  write  or  contemplate  writing 
nonscientific  articles  for  medical  journals  that  permission  was 
sought  for  its  jmblication  in  the  Medical  .Vnnals.  Mr. 
Richardson  seemed  somewhat  surprised,  but  gladly  consented 
to  its  being  used. 


article  or  two  a month  on  some  social  or  economic 
or  otherwise  nonscientific  aspect  of  medical  practice 
. . . don’t  you  think?” 

Sure,  I said,  as  long  as  you  don’t  bite  off  more 
than  you  can  chew  and  attempt  what  I call  multi- 
source articles — meaning  those  that  require  the  tal- 
ents of  several  collaborators  if  they’re  going  to  be 
really  authoritative.  Take  an  e.xample: 

number  of  Medical  Economics  readers  awhile 
ago  asked  us  to  discuss  the  problem  of  whether  a 
doctor  who  couldn’t  otherwise  collect  his  fee  from  a 
patient  should  sue  him.  Once  we  decided  to  get  such 
an  article  the  question  was:  From  whom? 

lawyer  might  well  lack  the  physician’s  feeling 
for  the  ethical  considerations.  physician — even  the 
chairman  of  a medical  ethics  committee — would  not 
have  the  legal  training  necessary.  A professional 
management  consultant  might  know  only  how  suing 
patients  affects  the  business  side  of  the  doctor’s 
[iractice.  And  a professional  writer-  even  a science 
writer  -would  lack  the  background  to  do  such  a 
many-sided  job  right  without  weeks  of  research. 

Whom  to  get  then?  Who  would  be  the  yiroper  source 
of  an  article  on  suing  delinquents?  Obviously,  no  one 
of  the  people  mentioned  but  all  four,  .^nd  it  was 
from  all  four,  acting  in  collaboration,  that  we  finally 
got  the  article.  The  experts  in  ethics,  law,  and  busi- 
ness supjdied  the  basic  material.  The  writer  put  it 
into  interesting,  readable  form.  The  lawyer  checked 
it  for  accuracy  and  signed  it.  .^nd  all  were  paid. 

If  a state  medical  journal  editor  can  command 
such  assorted  talents  without  having  to  pay  for 
them,  well  and  good,  but  it  doesn’t  often  happen. 
Esually,  I told  Ed,  your  cue  will  be  to  skip  such 
multi-source  articles  as  I’ve  described,  and  go  after 
single-source  articles  instead.  Of  course,  even  a per- 
suasive editor  becomes  less  so  if  he  continues  to  ask 
the  same  people  to  contribute  gratis  to  his  journal. 
He  soon  runs  into  excuses,  broken  promises,  and, 
finally,  flat  refusals. 

Let’s  be  realistic  about  it.  .\nyone  who  takes 
valuable  time  to  prepare  or  help  prepare  articles  for 
you  must  have  an  incentive.  The  incentive  among 
your  physician-contributors  is  usually  prestige,  or 
reputation-building,  .\mong  other  potential  contrib- 
utors, it’s  often  (though  not  always)  money. 


42 


VOL.  XXI,  NO.  1 


Medical  Annals  of  the  District  of  Columbia 


43 


If  a physician  writes  a good  scientific  article  and 
gets  it  published  in  a good  medical  journal,  he  knows 
that,  even  though  he’s  not  paid  for  it,  it  will  enhance 
his  professional  standing.  Not  so  if  he  writes  a non- 
scientific  article.  He’s  primarily  a doctor,  not  a busi- 
nessman. So  building  a reputation  in  business  is  of 
little  interest  to  him.  He  may  work  with  you  on  one 
or  two  such  articles  as  a personal  favor.  But  that’s 
usually  as  far  as  you  can  expect  him  to  go  unless 
he’s  under  some  special  obligation  or  unless  he’s  paid 
for  his  time. 

Even  if  you  had  plenty  of  contributors  on  tap 
who  would  donate  free  all  the  time  you  needed, 
you’d  still  be  up  against  it,  I told  Ed.  F'or  the  plain 
fact  is  that  few  professional  men  —whether  doctors, 
lawyers,  accountants,  architects,  or  otherwise — have 
the  writing  ability  of  even  a lesser  De  Kruif.  And 
most  of  those  who  do  always  seem  to  be  too  busy, 
or  they’re  just  about  to  leave  on  a trip,  or  they’ve 
just  come  back  from  one  and  are  allegedly  snowed 
under. 

Now  assuming  the  ridiculous:  that  you  had  a 
group  of  contributors  who  could  write  like  Osiers 
and  who’d  give  you,  free  of  charge,  all  the  time  you 
wanted.  There  would  be  still  another  hard  morsel  to 
swallow,  and  that’s  the  subject  matter.  Take  the 
Saturday  Evening  Post  writer  who  spends  a balmy 
February  cruising  the  West  Indies  on  an  expense 
account,  tapping  out  a little  article  about  it  and 
getting  paid  SI, 000  or  so  into  the  bargain.  Nice 
work,  you  say.  Now,  for  contrast,  think  of  the  lucky 
M.D.  assigned  by  his  state  journal  editor  to  do  a 
colorful,  exciting  article  on,  say,  the  relative  admin- 
istrative costs  of  nonprofit  versus  commercial  health 
insurance  carriers. 

Clarence  Roy,  formerly  on  the  editorial  staff  of 
Medical  Economics,  came  to  us  after  a number  of 
years  spent  as  senior  article  editor  of  Colliers.  “You 
warned  me,”  he  said  once,  “that  articles  about  eco- 
nomics are  hard  to  make  interesting.  It  was  the 
understatement  of  your  life.” 

Ed  wasn’t  one  to  let  me  reminisce  long.  He  inter- 
rupted here  to  say,  “Look.  I thought  you  had  some 
constructive  ideas  for  me.  So  far,  they’ve  all  been 
negative.  How  about  it?” 

I admitted  he  was  quite  right.  I had  sim[)ly  wanted 
to  begin  the  talk  at  the  j)roj)er  level  to  j)oint  uj) 
what  I’d  said  about  social  and  economic  articles  at 
the  start:  Don’t  bite  off  more  than  you  can  chew. 


Better  to  do  a few  good  articles  of  this  kind  than  a 
lot  of  poor  ones. 

Now  for  some  more  practical,  positive  suggestions: 

Each  state  medical  society  should  decide,  as  a 
matter  of  basic  policy,  what  it  wants  its  journal  to 
be.  .4nd  you,  I told  Ed,  are  the  trustee  of  that  policy 
— the  one  responsible  for  carrying  it  out. 

At  present,  there  are  three  schools  of  thought: 
One  holds  that  a state  medical  journal  is  primarily 
a vehicle  for  postgraduate  medical  education  and 
should  be  made  up  almost  exclusively  of  scientific 
articles.  The  second  school  holds  that  scientific  arti- 
cles belong  in  the  J.A.M.A.,  in  O.P.,  and  in  the 
specialty  journals;  that  a state  journal  is  primarily 
a house  organ  for  organized  medicine  at  the  state 
level;  and  that,  therefore,  the  bulk  of  its  material 
should  be  organizational,  economic,  and  otherwise 
nonscientific.  The  third  school  is  of  the  oi)inion  that 
a state  medical  journal  should  be  all  things  to  all 
members;  that  it  must  consequently  find  room  for 
scientific  papers,  organizational  news,  and  articles 
on  the  social,  economic,  and  all  other  aspects  of 
medical  practice.  Ed  said  he  doubted  that  his  state 
medical  society  had  ever  even  thought  of  blueprint- 
ing its  journal  policy  so  specifically.  In  that  case,  I 
told  him,  the  time  is  coming  when  it  will  have  to  do 
so;  and  you  had  better  try  to  speed  the  day — if  only 
so  you,  as  editor,  will  know  what’s  expected  of  you. 

In  times  past,  medical  journal  editors  took  pretty 
much  what  came  to  them.  Now  they’re  beginning 
to  have  to  shape  their  journals  to  the  needs  of  their 
readers.  Reasons  for  this  are  the  mushrooming  of 
medical  literature  on  all  sides,  a growing  restiveness 
among  doctors  at  having  to  contend  with  so  much 
of  it,  and  the  consequent  demand  for  greater  selec- 
tivity. 

E.xcept  in  teaching  centers  and  under  other  un- 
usual circumstances,  the  state  medical  journal  editor 
may  well  find  his  future  supply  of  good  scientific 
articles  dwindling.  More  and  more,  the  best  research 
articles  are  going  to  the  specialty  journals.  State 
journals,  with  the  exceptions  noted,  are  finding  it 
ever  more  difficult  to  meet  the  comjietition  of  the 
specialty  journals  for  topflight  scientific  papers. 

Sir  Thomas  Lewis,  as  an  individual  practitioner, 
could  draw  pioneer  deductions  from  his  .solo  obser- 
vations on  clinical  cardiology.  But  nowadays,  less 
that  is  new  or  important  develops  that  way. 

Research  is  increasingly  the  ])roduct  of  teams, 
foundations,  schools,  and  laboratories.  The  solo  doc- 


44 


Editor  Talks  Shop — Richardson 


JANUARY,  1952 


for  is  still  the  major  contributor  to  the  state  medical 
journal;  but  because  of  the  changing  nature  of  re- 
search, he  has  less  to  contribute  in  the  form  of  basic 
scientific  progress. 

bid  didn’t  seem  entirely  sold  on  this  bit  of  reason- 
ing. But  I continued  anyway. 

Will  you,  I asked  him,  be  content,  in  view  of 
the  trend,  to  sit  by  and  let  the  specialty  journals 
monopolize  the  best  scientific  stuff,  thus  compromis- 
ing with  quality?  Or  will  you  publish  somewhat 
fewer  (but  good)  scientific  articles  and  somewhat 
more  nonscientific  ones? 

He  thought  he’d  have  to  think  that  one  over. 

“Do  you  have  any  doubts,”  he  asked  me,  “about 
the  appropriateness  of  nonscientific  articles  in  a 
scientific  state  medical  journal?” 

I said  no,  I hadn’t,  because  a state  medical  journal, 
in  my  view,  is  not  exclusively  a scientific  journal. 

Be  that  as  it  may,  I said,  I thought  the  non- 
scientific article  lends  itself  particularly  well  to  med- 
ical journalism  at  the  state  level.  Why?  Because  the 
doctor  really  belongs  to,  and  feels  a part  of  his  state 
society — more  so,  quite  naturally,  than  of  his  very 
much  larger  national  association. 

As  a matter  of  fact,  I pointed  out,  the  volume  of 
such  material  in  state  journals  in  recent  years  has 
grown  tremendously,  as  witness  the  many,  many 
articles  on  medicine’s  public  relations,  its  grievance 
committees,  its  night-call  bureaus,  its  attempts  to 
guarantee  the  best  medical  care  to  all  the  people, 
under  private  practice. 

How  can  any  doctor  who  wants  to  be  well  in- 
formed not  read  about  important  new  changes  in 
the  mechanics  of  medical  organization,  about  the 
profession’s  political  problems,  about  the  rising  tide 
of  voluntary  health  insurance  (with  its  emphasis  on 
careful  record-keeping,  fee-scheduling,  and  the  like)? 

(Juite  frequently,  I remarked,  a nonscientific  arti- 
cle in  a state  journal  will  relate  itself  to  an  M.D.’s 
day-by-day  work  in  a way  that  few  scientific  arti- 
cles do. 

In  a recent  issue  of  one  state  journal,  for  example, 
there  were  four  scientific  articles  and  several  non- 
scientific ones.  The  scientific  articles  discussed  a rare 
disease  of  the  spleen,  the  advanced  aspects  of  liver- 
function  testing,  the  surgical  removal  of  a lobe  of 
the  thyroid,  and  one  man’s  experience  with  foreign 
bodies  in  the  eye. 

'Fhe  nonscientific  material  included  a statement 


about  filing  bills  for  home-town  care  of  veterans;  a 
piece  about  a chiropractic  bill  before  the  state  legis- 
lature; some  suggestions  from  the  state’s  attorney 
general  about  writing  prescriptions  for  barbiturates; 
a proposed  amendment  to  the  society’s  constitution; 
a calendar  of  hospital  staff  meetings;  and  an  editorial 
supporting  an  M.D.  who  had  refused  to  contribute 
under  pressure  to  a hospital  fund. 

I’m  not  derogating  the  value  of  the  four  scientific 
articles  one  bit;  nor  am  I saying  that  the  nonscien- 
tific material  made  perfect  bull’s  eyes.  I am  saying 
that  the  latter  was  quite  as  useful  to  the  reader  as 
the  former;  and  I think  the  editor  showed  good 
judgment  in  giving  the  nonscientific  articles  as  much 
space  as  he  did. 

.\s  I told  Ed,  the  appropriateness  of  socioeco- 
nomic material  in  a state  medical  journal  raises  no 
question.  The  real  nut  the  editor  must  crack  is:  How 
to  get  such  articles? 

I’m  convinced  you  can  get  them,  I said  at 
least  a good  many  types.  So  now  a few  words  on 
how.  Let  me  cite  some  real-life  e.xamples: 

When  the  F.S.A.  predicted  an  alarming  doctor- 
shortage  by  1960,  one  state  medical  journal  editor 
got  a local  statistician  to  disprove  the  claim.  The 
article  he  wrote  attracted  all  sorts  of  attention  be- 
cause it  was  good  and  because  it  reflected  some 
fresh,  original  thinking.  It  also  furnished  fuel  for 
the  society’s  speakers’  bureau,  and  it  gave  rank- 
and-file  doctors  some  valid  retorts  to  use  in  social 
conversations  that  turned  to  the  alleged  shortage. 

\Mien  newspapers  headlined  the  black  market  in 
babies,  one  state  journal  editor  got  his  state  welfare 
department  to  assign  a writer  to  explain  the  state’s 
rather  complicated  adoption  law.  This,  and  an  ac- 
companying editorial,  not  only  made  interesting 
reading  but  actually  straightened  out  the  thinking 
of  some  of  the  journal’s  own  readers. 

Another  editor  based  a first-rate  article  on  a re- 
port of  his  society’s  committee  on  laboratory  med- 
icine, discussing  the  legal  status  of  laboratories  op- 
erated by  laymen.  Still  another  got  a hospital 
chief-of-staff  to  write  a story  on  how  his  institution’s 
general  practice  service  was  functioning  after  a year’s 
trial. 

These  examples,  I think,  are  enough  to  illustrate 
the  point  as  it  relates  to  articles.  There’s  great  scope, 
too,  for  letters  to  the  editor  (if  you’re  not  already 
using  them).  Such  letters  in  Medical  Economics  (we 


VOL.  XXI,  NO.  1 


Medical  Annals  of  the  District  of  Columbia 


45 


know  from  our  readership  reports)  are  among  the 
most  read  items  each  month. 

.4fter  all,  why  not  give  the  reader  a forum  for  his 
views?  Isn’t  he  entitled  to  it?  Nonscientific  material 
is  a “natural”  for  this  purpose.  Here  are  a few  e.x- 
amples  of  such  letters  submitted  to  state  journals. 
Think,  if  you  can,  of  copy  more  likely  to  attract 
reader-interest.  For  instance: 

^ A protest  against  an  alleged  monopoly  in  cancer 
biopsy  specimen  readings,  charging  that  only  mem- 
bers of  the  state  society  of  pathologists  were  allowed 
to  work  on  the  program. 

^ A charge  of  overemphasis  on  board  certihcation 
in  hospital  staff  appointments. 

^ A discussion  of  the  problem  of  whether  mothers 
should  be  allowed  to  offer  their  own  babies  for  adop- 
tion, without  Government  regulation. 

^ A query  about  whether  it’s  all  right  ethically 
to  mail  patients  reminders  of  health  examination 
appointments. 

^ An  expression  of  opinion  that  lobbying  is  a legiti- 
mate function  of  organized  medicine. 

^ A statement  that  hospital  staff  men  should  be  re- 
tired automatically  at  65  to  make  room  for  younger 
men,  and  so  on. 

When  I saw  Ed  on  another  occasion  later,  he 
asked  me  what  luck  I thought  he’d  have  soliciting 
nonscientihc  articles  and  news  by  mail  and  phone. 
My  answer  was  the  same  one  I’ve  given  many  times 
before:  There’s  no  substitute  for  contacts  made  in 
person.  If  there  were,  newspapers  would  not  still  be 
paying  reporters  to  get  their  news  for  them. 

As  a state  journal  editor,  you  know  that  many 
such  contacts  are  possible  at  meetings  over  the 
luncheon  table,  at  the  hospital,  and  elsewhere.  To 
make  these  contacts,  you  have  not  only  yourself 
but  your  assistants,  your  correspondents  around  the 
state,  your  held  secretary  (if  the  state  society  em- 
ploys one),  plus  any  of  the  society  officers  and  mem- 
bers you  can  recruit  as  volunteer  “idea  men.” 

Xot  all  these  peo[)le  will  be  sources  of  articles. 
Hut  a number  of  them  should,  if  encouraged,  come 
up  with  i leas  for  articles  and  with  short  news  items. 

The  society  officers  have  a special  obligation  to 
see  that  the  society  and  all  its  works  (the  journal 
included)  succeed.  So  if  you’re  u[)  against  it  at  any 
time,  you  can  very  [)roperly  put  some  pressure  on 
them  to  helj)  you  out. 

Harking  back  again  now  to  those  published  re- 


ports of  medical  society  councils  and  committees, 
I told  Ed  I’d  like  to  make  what  I consider  a highly 
important  point  for  every  state  journal  editor:  Too 
many  valuable  news  items  or  articles  are  found  bud- 
ding in  these  committee  reports  only  to  wither  with- 
out blooming.  If  you  feel  it’s  good  practice  to  pub- 
lish such  reports  verbatim,  all  right.  But  don’t  let  it 
go  at  that.  See  that  those  nev/s  buds  bloom  some- 
where in  your  journal.  And  make  sure  they  don’t 
bloom  unseen. 

Base  separate  new  stories  on  the  most  interesting 
committee  reports.  (Such  stories  will  probably  at- 
tract a lot  wider  readership  than  the  reports  them- 
selves.) They  have  another  value,  too.  Since  the 
news  story  is  much  shorter  than  the  full  report  and 
can  usually  be  written  well  in  advance  of  the  re- 
port’s publication,  you  stand  a good  chance  of  get- 
ting it  into  an  earlier  issue  and  thus  having  it 
reach  the  reader  while  still  fresh. 

If  you  report  on  a meeting,  I advised  Ed,  tell 
what  happened.  Avoid  provoking  the  reader’s  curios- 
ity and  annoyance  by  merely  stating  that  such  and 
such  a meeting  was  held  and  that  “several  interesting 
topics  were  discussed.”  Capsule  the  results  instead. 
Report  all  the  worthwhile  facts  and  oj)inions  ex- 
pressed. If,  separately,  in  an  editorial,  you  can  give 
your  own  personal  impressions  of  the  meeting,  so 
much  the  better. 

If  you  doubt  the  prevalence  of  that  annoying 
habit  I mentioned — the  habit  of  naming  all  the  in- 
triguing things  discussed  without  telling  what  they 
w'ere,  here  are  just  a couple  of  examples  taken  from 
the  November,  1951  issues  of  state  journals: 

E.xample  One:  “The  problem  of  the  relationship 
between  hospitals  and  physicians — especially  as  re- 
gards anesthesiology,  pathology  and  radiology — was 
again  aired,  by  means  of  a symposium  during  the 
convention.” 

Example  Two:  “He  told  what  had  been  done  in 

County  with  reference  to  the  creation  of  a 

health  council.” 

These  are  but  two  exami)les.  1 have  others.  In 
each  case  the  reader’s  curiosity  is  piqued  by  a rather 
vital  topic.  But  he  is  then  left  high,  dry,  and  frus- 
trated. 

1 also  suggested  to  Ed  that  when  he  ])ublishes  the 
proceedings  of  a meeting,  or  bases  an  article  on  it, 
he  avoid  labeling  it,  for  instance,  “Rei^ort  of  Meeting 
of  Nov.  l.Ith.”  This  may  do  as  a .subtitle,  for  irlenti- 


46 


Editor  Talks  Shop — Richardson 


JANUARY,  1952 


lication;  but  the  main  title  should  state  the  gist  of 
what  happened  and  be  so  worded  as  to  capture  the 
reader’s  eye. 

Some  good  articles  have  as  many  as  three  or  four 
subtitles,  plus  column  headings  and  other  typo- 
graphical devices  that  tell  the  reader  clearly  what 
the  article  as  a whole  (and  what  each  of  its  sections) 
is  all  about. 

.\  good  column  heading  on  a page  often  inveigles 
a man  into  a story  that  he  skipped  at  the  start.  It 
breaks  up  the  page,  too,  and  makes  for  easier  reading. 

I didn’t  know  whether  Ed’s  society  was  one  of 
those  that  publishes  a handbook  for  its  members— 
a book  that  tells  them  what’s  what  with  respect  to 
state  medical  licensure,  state  laws  affecting  medical 
practice,  state  ta.xes,  local  interpretation  of  the  prin- 
ciples of  medical  ethics,  local  public  health  regula- 
tions, state  medical  and  hospital  statistics,  local  vol- 
untary health  insurance  plans,  and  so  forth. 

If  it  did  have  such  a handbook,  I suggested  that 
too  might  be  a good  teeing-off  point  for  socioeco- 
nomic articles.  No  handbook  of  this  kind  is  intended 
to  be  read  through  at  one  time.  It’s  a reference 
book,  pure  and  simple.  Much  of  what’s  in  it,  if  up- 
dated, rewritten  interestingly  in  article  form,  and 
presented  attractively,  can  be  depended  upon  to 
draw  readershi]!. 

Why?  Because  it’s  important  stuff.  It  gives  the 
local  approach  to  each  problem  raised.  .And  readers 
can’t  get  it  anywhere  else — even  in  a publication 
like  Medical  Economics  that  devotes  all  its  space  to 
things  social  and  economic  but  that  necessarily 
takes  a national,  rather  than  a local,  viewpoint. 

I assume  that  the  typical  state  medical  journal 
editor  subscribes  to  one  or  more  news-clipping  serv- 
ices or  has  a girl  who  clips  for  him  the  leading  news- 
papers in  his  state  and  the  many  other  printed 
media  from  which  he  can  extract  article  and  editorial 
ideas.  Not  all  such  editors,  though,  base  news  items 
on  these  clips.  Nor  do  they  often  quote  pertinent 
press  comments.  It’s  an  idea  worth  considering. 

.Another  worthwhile  kind  of  material  you  can  get 
is  what  we  call  a handitip.  It’s  actually  no  more 
than  a practical  nugget  or  suggestion  designed  to 
help  the  reader  save  time,  money,  or  effort  in  the 
dailv  conduct  of  his  practice.  But  it’s  a highly  popu- 
lar type  of  material.  Handitips,  we  find,  are  best 
picked  up  directly — in  the  course  of  visiting  readers 
in  their  own  offices. 


.A  state  journal  editor,  I reminded  Ed,  can  also 
solicit  material  from  men  in  the  other  professions 
and  in  business.  These  men  have  an  incentive  to 
write  for  you.  The  doctor  is  their  client.  They’re 
often  delighted  to  get  their  ideas  over  to  medical 
men  -and  at  no  cost  to  you. 

.A  professional  management  firm  I know  of  was 
invited  some  years  ago  by  the  editor  of  the  state 
medical  journal  to  do  an  article  on  medical  collection 
technics.  Since  then,  all  sorts  of  articles  have  been 
obtained  from  this  firm  and  published  in  this  journal, 
with  mutual  advantage. 

I needn’t  dwell  on  the  need  to  be  careful  in  choos- 
ing such  contributors.  If  anything  such  a man  says 
indicates  that  he  may  be  out  mainly  to  “sell”  the 
reader  something,  or  if  it  suggests  an  unwholesome 
bias  or  one-sidedness,  it’s  time  to  steer  clear.  You 
can’t  afford  to  be  taken  in  by  anyone  who  would  sell 
the  reader  a bad  bill  of  goods.  I’m  not  talking  about 
the  obvious  case  here,  but  the  subtly  disguised  one. 
.A  skeptical,  challenging  attitude  is  your  only  pro- 
tection. 

One  of  my  own  friends,  a respected  figure  in  the 
insurance  business,  has  urged  several  articles  on  me. 
But  I won’t  take  them.  What  he  writes  is,  at  first 
reading,  altogether  plausible.  But  he’s  so  biased  in 
his  own  approach  (perhaps  he  can’t  help  it)  that  he 
fails  to  give  the  reader  both  sides  of  a situation. 
Unfortunately,  the  reader  may  not  even  know  there 
is  another  side;  so  we  feel  it’s  up  to  us  to  play  watch- 
dog for  him. 

.Articles  from  people  in  allied  professions  don’t 
usually  raise  such  problems.  .And  they’re  not  hard 
to  get  because  a dentist,  druggist,  or  nurse,  for  ex- 
ample, is  often  complimented  by  an  invitation  to 
fill  an  assignment  for  the  state  medical  journal. 

I come  now  to  what  I regard  as  another  vital 
policy  for  state  medical  journal  editors.  When  I 
talked  with  Ed  about  it,  I put  it  more  or  less  in 
these  words: 

Don’t  try,  as  a rule,  for  articles  of  national  scope. 
These  are  necessarily  broad-based;  they  demand 
broad-scale  research;  they’re  expensive  to  get;  and 
the  national  journals  take  care  of  them  anyway. 

By  the  same  token,  don’t  reprint  articles  of  na- 
tional scope  that  have  appeared  in  journals  of 
national  circulation.  They’ll  be  old  stuff  by  the 
time  you  get  around  to  them,  and  you’ll  get  a repu- 
tation for  devoting  your  journal  to  pickups  instead 
of  to  original  cojw. 


VOL.  XXI,  NO.  1 


Medical  Annals  of  the  District  of  Columbia 


47 


The  lead  articles  in  the  current  issues  of  at  least 
two  state  journals  make  this  very  error.  They  report 
in  detail  pieces  of  Washington  news  that  made  head- 
lines last  summer.  And  they  don’t  add  one  new 
thought  to  the  original. 

I repeat,  then;  Don’t  try  for  national  articles  in 
a state  journal  Instead,  when  it  comes  to  important 
national  news,  report  the  local  side  of  it.  To  il- 
lustrate: 

If  a survey  is  made  of  doctors’  incomes  in  the 
United  States,  try  to  get  the  income  figures  for  your 
state.  Show  the  various  breakdowns  in  your  state. 
If  some  big  national  news  occurs  in  Blue  Shield, 
try  to  pick  out  and  report  the  parts  of  it  that  affect 
your  state  in  particular. 

Once  you’ve  reported  all  the  facts  from  a national 
story  that  apply  exclusively  to  your  state,  you  have 
another  opportunity.  And  that  is  to  interpret  those 
facts,  often  in  an  editorial. 

In  every  national  story,  then,  look  for  the  local 
twist.  You’ll  then  have  something  new  and  different 
for  your  readers.  Actually,  in  publishing  local  facts 
and  opinions  about  national  developments  lies  your 
big  chance  to  make  a real  contribution  to  the  social 
and  economic  side  of  medical  journalism.  Some  jour- 
nals recognize  this  already.  Others  have  not  heard 
opportunity  knocking. 

They  may  have  overlooked  the  fact,  too,  that  in 
giving  their  readers  the  local  slant  on  national  news, 
they’re  in  the  enviable  position  of  having  no  edi- 
torial competition  whatever.  The  field  is  wide  open. 
Medical  Economics,  for  example,  can’t  possibly  delve 
into  the  local  aspects  of  a story,  except  in  those 
cases  which  have  national  significance. 

Selecting  the  local  news  from  a larger  piece  of 
national  news  is  generally  a job  for  the  state  journal 
editor  or  an  assistant.  The  same  may  be  true  of  the 
job  of  interpreting  such  news;  though  here  it  is  often 
possible  to  invite  the  opinions  of  others. 

Most  people  don’t  enjoy  the  hard  work  that  pains- 
taking research  demands.  But  they  enjoy  exjiressing 
their  opinions.  It’s  easy.  It’s  fun.  And  it  inllates  the 
ego  without  further  inflating  the  dollar. 

If  you’re  not  already  doing  so,  then,  you  may  find 
it  worthwhile  to  invite  guest  editorials.  Try  the  (lov- 
ernor  of  your  state,  if  the  subject  is  one  he’s  likely 
to  have  an  opinion  on,  or  a leading  newspai)er  editor, 
or  a public  health  officer,  or  bank  [)resident,  or  labor 
leader.  The  possibilities  are  legion. 


If  you  think  that  asking  him  for  an  editorial  may 
strike  him  as  too  formidable  a task,  invite  a long 
letter  instead,  or  interview  him. 

You  can,  of  course,  develop  editorial  writers 
among  your  society  members  as  well.  It  takes  work 
to  do  this;  but  it  may  pay  handsome  dividends  at 
deadline  time,  (live  such  a man  a news  item,  for 
e.xample.  Let  him  point  out  its  significance  to  doctors 
in  your  state.  Several  state  (and  county)  journals 
have  been  doing  this  with  telling  effect.  Such  guest 
editorials  needn’t  be  lengthy.  They  take  no  digging 
for  facts.  So  they’re  relatively  easy  to  prepare. 

The  main  thing  is  to  be  sure  of  your  man — sure 
that  he  knows  his  subject  and  will  bring  sound 
judgment  to  it. 

When  Columnist  Bob  Ruark  recently  made  some 
cogent  remarks  about  medicine  for  his  Scripps- 
Howard  readers,  the  editor  of  the  medical  society 
journal  in  Ruark’s  home  state  was  alert  enough  to 
reprint  the  columnist’s  remarks  for  local  doctors  and 
to  append  his  own  point  of  view. 

Another  state  journal  editor  recently  reported  and 
discussed  the  Federal  hospital  building  program  in 
terms  of  how  it  would  affect  hosjritals  and  doctors 
in  his  state. 

Still  other  state  journal  editors  have  lately  shown 
how  their  doctors  will  be  affected  by  calls  to  military 
service,  by  Federal  grants  for  civil  defense  stock- 
piling, by  the  diabetes  detection  drive. 

Speaking  of  the  diabetes  drive,  how  much  better 
to  give  it  this  local  twist  than  to  do  as  one  state 
journal  did  and  merely  print  the  handout  from 
national  headquarters. 

Cuest  editorials — likewise  signed  articles  of 
opinion  -have  a prime  virtue  that’s  often  over- 
looked. They  allow  you  to  plunge  into  really  stimu- 
lating controversial  issues  without  committing  the 
journal  or  the  society  as  such.  If  the  view  expressed 
is  completely  at  variance  with  the  society’s,  all  the 
editor  has  to  do  is  say  so  in  an  editor’s  note  Readers 
recognize  the  value  of  free  speech.  In  medical  jour- 
nals, I maintain,  there  ought  to  be  more  of  it. 

While  we’re  on  the  subject  of  editorials,  1 should 
perhai)S  say  I reminded  Fd,  in  his  early  days,  that 
an  editorial  is  an  expression  of  opinion.  It  is  not  a 
news  report.  It  contains  more  than  facts.  Usually  it 
interprets  something.  Sometimes  it  exhorts  the 
reader  to  action.  Xow  and  then  it  simply  views  with 
alarm. 


48 


Editor  Talks  Shop — Richardson 


JANUARY,  1952 


Here’s  another  important  j)oint  I tried  to  get 
over  to  Ed: 

Resides  giving  the  local  slant  on  national  news, 
a state  medical  journal  may  very  properly  give  a 
national  slant  if  it’s  new,  original  and  different.  One 
paragraph  in  a recent  state  journal  editorial,  for 
instance,  begins  with  these  words,  “A  most  im- 
portant factor  in  physicians’  incomes  was  not  even 
mentioned  in  the  Commerce  Department  report. 
And  it  was  barely  suggested  in  the  AMA’s  discus- 
sion” (and  so  on).  Here’s  a cue  that  the  writer  of  the 
editorial  dug  beneath  the  surface,  that  he  has  come 
up  with  a new,  fresh,  original  angle.  So  the  reader  is 
all  ears. 

I’ve  advised  strongly  against  a state  medical 
journal  reprinting  national  news  from  a national 
medical  journal,  and,  if  necessary.  I’ll  repeat  the 
advice.  But  quoting  a small  part  of  a national  medi- 
cal story  that  relates  specifically  to  your  state — or 
that  can  be  so  interpreted — is  another  matter,  and 
amply  justified.  Medical  Economics,  for  one,  is  glad 
to  allow  such  quotations — up  to  300  words — without 
any  formal  request  (but  with  credit,  since  the  ma- 
terial is  copyrighted). 

Another  thing  I suggested  to  Ed:  When  you  get 
your  clutches  on  a local  story  that’s  really  good, 
don’t  just  mention  it  in  a brief  news  item,  (live  it 
the  “full  treatment,”  that  is,  a complete  article  or 
even  a series  of  articles. 

Ed  asked  me  whether  I thought  a medical  journal 
should  run  its  socioeconomic  material  in  a special 


section  set  apart  by  its  position  and  perhaps  also 
by  a different  colored  stock. 

Frankly,  I don’t  think  this  question  is  of  con- 
suming importance.  Anything  you  can  do,  within 
reason  and  good  taste,  to  make  an  article  or  depart- 
ment capture  reader  attention  merits  thought.  But 
the  substance  of  what  you  say — and  how  you  say  it 
— is  the  main  thing.  An  attractive  office,  we  all 
know,  helps  sell  a doctor  to  his  patients.  Yet  it’s  the 
doctor  himself  in  the  final  analysis  who  tips  the 
choice. 

While  my  staff  clips  most  of  the  state  medical 
journals  each  month,  I had  not  recently  had  occa- 
sion, until  last  week,  to  examine  a good  cross-section 
of  them  at  one  sitting,  with  an  eye  to  their  socio- 
economic content. 

My  reaction,  when  I did  so,  was  twofold:  First, 
that  the  quality  of  such  material  in  the  better  state 
journals  had  risen  immeasurably,  and,  second,  that 
this  gain  served  to  throw  into  sharper  relief  than 
ever  the  journals  that  are  not  doing  a good  job. 

At  one  time  or  another.  I’ve  edited  magazines 
whose  editorial  budgets  have  ranged  from  zero  to 
six  figures  annually,  as  with  Medical  Economics. 
So  I realize  full  well  the  limitations  under  which 
the  better  state  medical  journals  operate. 

For  the  fine  work  they’re  doing  now,  for  the 
phenomenal  strides  they’ve  made  and  seem  about 
to  make  (in  the  face  of  overwhelming  financial  odds), 
my  hat’s  off  to  them. 


C.\LEND.\R  OF  SPEAKERS 

The  following 

members  of  the  Medical  Society  of  the  District  of  Columbia  have  addressed  lay  groups 

during  the  past  several  weeks.  The  Society  maintains  a Speakers  Bureau,  sponsored  by  the  Committee  on 

Public  Relations, 

through  which  requests  for  speakers  for  lay  groups  can  be  filled. 

Dale 

Speaker 

Subject  or  Title 

Organization 

November  19 

Dr.  Ceorge  Maksim 

Child  Care 

■Abram  Simon  Parent- 

Teachers  .Association 

November  19 

Dr.  Thomas  McP.  Brown 

The  M'onder  Drugs 

The  Torch  Club 

November  26 

Dr.  Henry  H.  Lichtenberg 

Discipline  in  the  Preschool 

Parents  of  Sixteenth  Street 

Child 

Highlands  Cooperative 

Nursery 

November  28 

Dr.  Dorothy  Donley  Dowd 

The  Psychological  .Aspects 

Business  and  Professional 

of  Charm 

Women’s  Club 

December  4 

Dr.  M.  Noel  Stow 

Cilaucoma — Createst  Cause 

I).  C.  Society  for  the  Pre- 

of  .Adult  Blindness 

vention  of  Blindness 

December  5 

Dr.  Arthur  C.  Christie 

.A  Longer  Life  and  a 
Healthier  One 

Rotary  Club 

The  first  International  Congress  of  Physical  Med- 
icine will  be  held  in  London,  July  14  to  19,  1952.  In 
accordance  with  the  regulations  of  the  International 
Federation  of  Physical  Medicine,  the  meetings  of 
the  Congress  will  be  reserved  for  matters  dealing 
with  the  clinical,  remedial,  prophylactic  and  edu- 
cational aspects  of  physical  medicine  and  with  the 
diagnostic  and  therapeutic  methods  employed  in 
physical  medicine  and  rehabilitation. 

Applications  for  the  Provisional  Programme 
should  be  addressed  to  the  Honorary  Secretary,  In- 
ternational Congress  of  Physical  Medicine  45,  Lin- 
coln’s Inn  Fields,  London,  W.C.  2. 

The  48th  Annual  Congress  on  Medical  Education 
and  Licensure  will  be  sponsored  by  the  Council  on 
Medical  Education  and  Hospitals  of  the  AMA  and 
the  h'ederation  of  State  Medical  Boards  of  the 
United  States.  The  meetings  will  be  held  in  the 
Palmer  House  in  Chicago,  February  10  to  12. 

The  National  Conference  on  Medical  Service  will 
convene  at  the  Palmer  House,  Chicago,  on  Sunday, 
February  10,  1952.  Dr.  Harlan  English,  of  Danville, 
Illinois,  will  be  this  year’s  Chairman;  the  Illinois 
State  Medical  Society  will  be  host.  The  theme  of 
the  meeting  is  “America’s  Next  Social  and  Health 
Crisis.’’ 

The  Mississippi  Valley  Medical  Society  offers  a 
cash  prize  of  S200,  a gold  medal,  and  a certificate 
of  award  for  the  best  unpublished  essay  on  any  sub- 
ject of  general  medical  interest  (including  medical 
economics  and  education)  and  practical  value  to 
the  general  practitioner  of  medicine  in  this,  the 
Twelfth  Annual  Essay  Contest  of  the  Society.  Cer- 
tificates of  merit  may  also  be  granted  to  the  physi- 
cians whose  essays  are  rated  second  and  third. 

Contestants  must  be  members  of  the  AM.\  and 
. citizens  of  the  United  States.  The  winner  will  be 
invited  to  present  his  contribution  before  the  17th 
.Annual  Meeting  of  the  Society,  to  be  held  in  St. 
j Louis,  Mo.,  October  1,  2 and  .1,  1952.  .Ml  contribu- 


tions shall  be  typewritten  in  English  in  manuscript 
form,  submitted  in  five  copies,  not  to  exceed  5,000 
words,  and  must  be  received  not  later  than  May  1, 
1952.  Further  details  may  be  secured  from  Dr. 
Harold  Swanberg,  Secretary,  Mississippi  \"alley 
Medical  Society,  209-224  W.C.U.  Building,  Quincy, 
111. 

The  name  of  the  Children’s  Country  Home  for 
Convalescent  Children  has  been  officially  changed 
to  The  Children’s  Convalescent  Home.  The  address 
is  unchanged,  1731  Bunker  Hill  Road,  X.E. 

The  Home  has  facilities  for  38  convalescent  and 
malnourished  children  ranging  in  age  from  infancy 
through  five  years.  In  general,  eligibility  for  admis- 
sion is  based  on  the  child’s  need  for  medical  super- 
vision preparatory  to  surgery,  during  recovery  from 
illness,  or  malnutrition.  Charges  are  based  on  the 
family’s  ability  to  pay  and  [)robable  period  of  care 
required.  Residence  is  not  a requirement  as  chil- 
dren are  acce{)ted  from  the  District  of  Columbia 
and  surrounding  counties,  and  from  hardship  tran- 
sient families. 

The  Home  is  maintained  by  a Board  of  Lady 
Managers,  of  whom  Mrs.  Jane  Wheeler  is  President. 
Dr.  Frederic  Burke  is  Medical  Director.  Mrs.  .An- 
nabelle  H.  Kent,  Administrator  of  the  Home,  ex- 
tends an  invitation  to  members  of  the  District 
Medical  Society  to  visit  the  institution  at  their  con- 
venience. 

Physicians  from  all  over  the  United  States  gath- 
ered in  Los  .Angeles,  (’alifornia,  December  4 to  7, 
for  the  Fifth  Annual  Clinical  Session  of  the  Ameri- 
can Medical  Association.  Representing  the  Medical 
Society  of  the  District  of  Columbia  at  the  meetings 
of  the  House  of  Delegates  were  Dr.  Herbert  P. 
Ramsey  and  Dr.  Hugh  11.  Hussey,  d'heodore  Wi[)rud, 
Secretary  of  the  Society,  was  also  present  for  the 
meetings  of  the  House.  Dr.  Oscar  B.  Hunter,  Sr., 
\'ice  President  of  the  .AM.A,  attended  the  meetings. 

Other  .Medical  Society  members  who  attended 
the  .AM.A  Session  were:  Drs.  Jacob  W.  Bird,  Ed- 


49 


50 


Xeii’s  and  Personals 


JANUAEY,  1952 


ward  H.  Cushing,  Richard  H.  Fischer,  Julius  Fogel, 
Joseph  S.  Lawrence,  J.  Winthrop  Peabody,  Alvin  R. 
Sweeney,  and  Frank  E.  Wilson;  also  Colonel  Joe  M. 
Blumberg  and  Major  Ceneral  David  X.  W.  Cirant. 

Dr.  John  \\’.  Cline,  of  San  Francisco,  President 
of  the  AMA,  addressed  the  assembly.  Dr.  Albert 
C.  Yoder,  of  Cioshen,  Indiana,  was  named  the 
“General  Practitioner  of  the  Year.” 

A feature  of  this  Clinical  Session  was  the  first 
transcontinental  transmission  of  color  television, 
presented  through  the  courtesy  of  Smith,  Kline  and 
French  Laboratories,  of  Philadelphia,  and  the  Co- 
lumbia Broadcasting  System.  The  program  orig- 
inated in  the  Los  Angeles  County  Hospital  where 
Dr.  John  C.  Jones,  surgeon,  performed  a coarcta- 
tion on  the  heart  of  Richard  C.  Russell  of  Pacoima, 
Calif.  Dr.  Jones  is  Associate  Professor  of  Surgery  at 
the  LTiversity  of  Southern  California  School  of 
Medicine.  The  operation  was  witnessed  by  physi- 
cians in  X^ew  York,  Chicago  and  Los  Angeles. 

Colonel  Joe  M.  Blumberg,  MC,  L"SA,  Patholo- 
gist in  the  Laboratory  Service  of  Walter  Reed  Army 
Hospital,  and  Dr.  \’ictor  M.  Sborov,  Director  of 
the  Hepatic  and  Metabolic  Center  of  Army  Medical 
Service  Graduate  School,  Walter  Reed  Army  Medi- 
cal Center,  presented  an  exhibit  on  the  subject, 
“Why  do  a liver  biopsy?” 

Rear  Admiral  T.amont  Pugh,  Surgeon  General  of 
the  N^avy,  presented  a paper  entitled,  “Modern 
Advances  and  Trends  m Military  Medicine,”  De- 
cember 7. 

Dr.  E.  P.  Luongo,  of  Los  Angeles,  an  Associate 
member  of  the  District  Medical  Society,  partici- 
I)ated  in  a (Question  and  Answer  Conference  on 
Overweight,  Xutrition  and  Health.  His  topic  was 
“The  Overweight  Executive — Problems  and  Pro- 
grams.” 

In  a scientific  exhibit  on  Control  of  Sound  and 
Xoise,  Dr.  Aram  Glorig,  of  Washington,  was  one  of 
several  jihysicians  who  showed  how  sound  absorb- 
ing materials  can  be  used  effectively  in  offices, 
hospitals,  operating  rooms,  and  industrial  plants. 

The  Executive  Board  of  the  Medical  Society  of 
the  District  of  Columbia,  at  its  regular  meeting, 
Xovember  26,  a[)proved  the  proposal  that  a joint 
meeting  be  held  with  the  District  Bar  Association 
on  March  5,  and  that  the  theme  of  the  meeting  be 
“Malpractice.”  • # 


President  Costenbader  proposed  the  name  of  Dr. 
Jonathan  M.  Williams  as  \'ice  General  Chairman 
of  the  Committee  on  Arrangements  for  the  1952 
Annual  Scientific  Assembly.  Dr.  William  J.  To- 
bin automatically  becomes  the  General  Chairman. 

Because  there  have  been  enough  volunteers  to 
meet  the  present  needs  of  the  Defense  Department, 
Selective  Service  has  postponed  again,  this  time 
until  February,  the  -call-up  of  485  physicians  for 
.\rmy  duty.  The  original  call-up  was  scheduled  for 
last  .August  and  September. 

The  11th  Annual  Conference  of  the  Maryland- 
District-Delaware  Hospital  Association  was  held  at 
the  Hotel  Statler,  Xovember  26  and  27. 

Mr.  Leo  G.  Schmelzer,  .Administrator  of  Garfield 
Hosjiital,  jiresided  at  the  opening  session.  The  wel- 
coming address  was  made  by  District  Commissioner 
F.  Joseph  Donohue. 

Dr.  Frank  D.  Costenbader,  President  of  the 
District  Medical  Society,  participated  in  a discus- 
sion on  “Trustee-Administrator-Medical  Staff  Re- 
lationship” with  Mr.  F.  .A.  Wardenburg,  trustee  of 
Memorial  Hospital,  Wilmington,  and  Sister  M. 
Yeronica,  R.S.M.,  Administrator  of  Mercy  Hospi- 
tal, Baltimore. 

Colonel  W.  L.  Wilson,  .Assistant  .Administrator 
of  the  Health  and  Welfare  Section,  Federal  Civil 
Defense  Administration,  and  Mr.  Robert  S.  Hoyt, 
.Administrator  of  Lutheran  Hospital,  Baltimore, 
discussed  “The  Role  of  the  Hospital  in  Civil  De- 
fense.” 

Dr.  .Anthony  J.  J.  Rourke,  President  of  the 
.American  Hospital  .Association  and  Medical  Super- 
intendent of  Stanford  University  Hospital,  San 
F'rancisco,  gave  the  principal  address  at  the  annual 
dinner. 

The  George  Washington  University  Medical  So- 
ciety held  its  second  meeting  of  the  season,  X’ovem- 
ber  28.  Dr.  Emil  Xovak,  .Assistant  Professor  of 
Gynecology  of  Johns  Hopkins  University,  was  the 
guest  speaker;  his  subject  was  “The  Relation  of  the 
Ovarian  Hormones  to  Eemale  Genital  Cancer.” 

The  Society  voted  to  change  its  regular  meeting 
date.  .All  future  meetings  will  be  held  on  the  third 
Y’ednesday  of  each  month  unless  members  are 
•■4)therwise  notified. 

1 


15  1953  4 


VOL.  XXI,  NO.  1 


Medical  A nnals  of  the  District  of  Columbia 


51 


The  Washington,  D.  C.  Section  of  the  American 
Congress  of  Physical  Medicine  had  a breakfast 
meeting,  November  28,  at  Gallinger  Municipal 
Hospital,  where  they  were  guests  of  Dr.  Josephine 
Buchanan.  Following  breakfast  the  group  inspected 
the  new'  set-up  of  the  physical  medicine  and  re- 
habilitation departments,  which  they  reported  to  be 
most  impressive. 

Dr.  James  P.  Kane  presented  a paper  on  “Term 
Pregnancy  Complicated  by  Ovarian  Teratoma”  be- 
fore the  George  M.  Kober  Medical  Society,  No- 
vember 19,  at  the  Army-Navy  Town  Club.  The 
paper  was  discussed  by  Dr.  Tomas  Cajigas. 

The  Society’s  Annual  Christmas  Party,  Decem- 
ber 17,  at  the  Shoreham  Hotel,  was  attended  by- 
wives  and  guests  of  members. 

Members  of  the  Clinico-Pathological  Society  were 
entertained  by  Dr.  John  Washington,  December  18, 
at  his  home  on  Olenbrook  Terrace.  Two  case  re- 
ports were  presented  during  the  evening’s  program: 
“Axillary  Tumor,”  Dr.  Thomas  Bradley  and 
“Acute  Rupture  of  the  Interventricular  Septum  in 
Myocardial  Infarction,”  Dr.  John  Minor. 

The  Washington  Academy  of  Medicine  held  elec- 
tion of  officers,  December  6.  The  following  members 
took  office  January  1 and  will  serve  for  two  years: 

Dr.  Walter  .\.  Bloedorn,  President;  Dr.  William  P.  Herbst, 
Vice  President;  Dr.  Errelt  C.  .\lbritton,  Secretary;  and  Dr. 
Roger  M.  Choisser,  Treasurer. 

The  medical  staffs  of  Alexandria  and  Arlington 
Hospitals  report  election  of  new  officers.  For  Alex- 
andria they  are: 

Dr.  Ben  ('.  Jones,  President;  Dr.  .\lbert  E.  Long,  Vice 
President;  and  Dr.  Richard  E.  Palmer,  reelected  Secretary. 

New  staff  officers  for  the  Arlington  Hospital  are: 

Dr.  .yifred  M.  Palmer,  Falls  Church,  Va.,  President;  Dr. 
Clifford  E.  Bagley,  Vice  President;  and  Dr.  K.  C.  Latven, 
Secretary. 

Most  of  these  officers  are  Associate  members  of 
the  District  Medical  Society;  Dr.  Bagley  is  an 
■Active  member  of  the  Society. 


Attention:  Readers 
Look  for  a new  series  of  articles  in  the  .Annals 
beginning  next  month.  Concerning  Those  Who 
Work  with  Us.  This  series  of  articles  is  designed 
to  acquaint  physicians  with  the  activities  and 
problems  of  those  in  the  ancillary  branches  of 
medicine,  i.e.,  dentists,  pharmacists,  podiatrists, 
nurses,  medical  technicians,  and  opticians 


Dr.  Howard  T.  Karsner,  Research  Adviser  to  the 
Surgeon  (ieneral  of  the  Navy,  was  honored,  De- 
cember 5,  by  receiving  the  Centennial  .Award  of 
Northwestern  University.  The  awards  were  pre- 
sented at  the  Centennial  Convocation  held  on  the 
Lhiiversity  campus,  December  2,  1951. 

The  recipient  was  one  of  a hundred  persons  hon- 
ored who  now  live  or  did  live  in  one  of  the  six  states 
of  the  original  Northwest  Territory.  The  award 
reads  in  part,  “.  . . in  recognition  of  the  impress 
which  he  has  made  during  a lifetime  of  distinguished 
service  as  a resident  of  one  of  the  states  which 
com[)rised  the  Northwest  Territory.” 

From  1914  to  1949,  prior  to  accepting  his  present 
position.  Dr.  Karsner  was  Professor  of  Pathology  at 
Western  Reserve  University.  He  is  President  of  the 
National  Board  of  Medical  Examiners;  Chairman  of 
the  Committee  on  Pathology,  Division  of  Medical 
Sciences,  National  Research  Council;  and  a mem- 
ber of  many-  medical  and  other  scientific  organiza- 
tions, including  the  District  Medical  Society,  in 
which  he  holds  .Associate  membership.  He  is  an 
Honorary  member  of  the  Society  of  Anatomy  of 
Brazil  and  the  Society  of  Pathology  of  Argentina. 

Dr.  Karsner  has  written  and  published  over  2.S0 
scientific  pajiers.  He  is  the  author  of  a widely  used 
textbook,  “Human  Pathology,”  which  is  now  in  its 
seventh  editifin. 

Dr.  Charles  M.  Griffith,  Manager  of  Mt.  Alto 
Veterans’  Administration  Hospital  since  1945,  re- 
tired, December  51,  after  more  than  54  years  of 
Government  service.  Dr.  Linus  A.  Zink,  former 
Manager  of  the  new  Brooklyn,  N.Y.,  Veterans  Hos- 
[)ital,  was  selected  to  succeed  Dr.  Griffith. 

Dr.  Gritfith  is  a graduate  of  the  Ihiiversity-  of 
'I*ennessee  School  of  Medicine.  He  served  in  the 


52 


News  and  Personals 


JANUARY,  1952 


Calendar  of  Meetings,  November  16 — 
December  15,  1951 

Subcommittee  of  Committee  on  Med- 
ical Care 

Washington  Psychoanalytic  Society 
Cooperation  with  D.  C.  Bar  Asso- 
ciation 

Grievance  Committee 
Special  Committee  on  Health  and 
Accident  Insurance 
Executive  Board 

District  Society  of  Anesthesiologists 
Membership  Luncheon 
Subcommittee  on  Child  Welfare 
Washington  Heart  Association 
Washington  Psychoanalytic  Society 
Committee  on  Scientific  Program 
Registered  X-ray  Technicians  of 
Washington 

Women’s  Medical  Society 
Executive  Board,  Woman’s  Auxil- 
iary 

Georgetown  University  Medical 
Alumni  Association 
Medical  Care  Services  for  Civil  De- 
fense 

Graduate  Nurses’  Association 
Section  on  Neurology  and  Psychi- 
atry 

Executive  Committee,  Gallinger 
Hospital 

Graduate  Nurses’  Association 


November  16 

November  17 
November  19 

November  20 
November  23 

November  26 

November  27 

November  28 
December  1 
December  3 
December  4 

December  5 


December  6 


December  7 

Special  Committee  on  Health  and 
Accident  Insurance 

December  10 

Committee  on  Blood  Banks 
Committee  on  Scientific  Program 
Board  of  Censors 

December  11 

House  Committee 

Medical  Officers’  Reserve  Units 

December  12 

Woman’s  Auxiliary 

Board  of  Censors 

Medical  Care  Services  for  Civil  De- 
fense 

December  13 

Washington  Psychiatric  Society 
Subcommittee  on  Mental  Health 

December  14 

Board  of  Censors 

Army  Medical  Corps  during  World  War  I.  After  a 
short  period  in  Public  Health  Service,  he  affiliated 
with  the  \'eterans  Administration  in  1924.  From 
1931  to  1945  he  was  Director  of  Medical  Services 
for  \hA. 


Dr.  Zink,  a graduate  of  Ohio  State  University' 
School  of  Medicine,  served  with  the  Army  Medical 
Corps  during  World  War  II.  He  was  separated  '■ 
from  the  service  as  a Lieutenant  Colonel.  He  was 
Clinical  Director  at  Alexandria  (La.)  \ A Hospital 
until  his  transfer  to  Brooklyn  in  1949.  j 

Dr.  William  Warren  Sager,  who  died  in  Rich- 
mond, Virginia,  September  10,  1951,  will  be  memo- 
rialized by  the  establishment  of  a research  fund  for 
paraplegia  subscribed  to  by  his  colleagues,  nurses, 
and  former  patients.  Dr.  Sager  himself  was  a paral- 
ysis victim.  From  November,  1949  until  his  death 
he  served  as  chief  of  the  cord  injury  service  at  the  ^ 
\’eterans  Administration  Hospital  in  Richmond; 
during  that  time  he  was  confined  to  a wheelchair. 

The  fund,  to  be  used  in  furthering  research  in  thej| 
field  of  spinal  paralysis,  will  be  administered  by  the 
National  Paraplegia  Foundation.  The  initial  con- 
tribution  to  the  fund  was  made  by  the  Virginiajj 
Chapter  of  Paralyzed  Veterans  of  America,  mem-J 
bers  of  which  are  present  or  former  patients  of  the* 
Richmond  Hospital.  Ij 

Dr.  Sager  was  Associate  Clinical  Professor  oflj 
Surgery  at  George  Washington  University  for  nearly  J 
20  years.  Enlisting  for  service  in  the  U.  S.  Na\y  f 
during  World  W^ar  H,  he  headed  the  general  surgical ) 
section  of  the  Navy  Medical  Center  in  Bethesda,  v 
Md.,  and  later  served  as  chief  of  surgery  aboard  the  ■ 
hospital  ship  V.  S.  S.  Sanctuary.  He  held  the  rank  : 
of  Commander.  ,, 

Dr.  Edward  B.  Tuohy,  Professor  of  Anesthesiology 
at  Georgetown  University  School  of  Medicine  since* 
1947,  resigned  his  position  with  the  University  as  off| 
November  19.  Dr.  Theodore  A.  Guenther,  Assist-  ■ 
ant  Professor  of  Anesthesiology,  was  named  to  sue-  • 
ceed  Dr.  Tuohy. 

Dr.  Tuohy  received  his  academic  degree  from  the : 
University  of  Minnesota  and  his  degree  in  medicines 
from  the  University  of  Pennsylvania.  He  held  a; 
fellowship  at  the  Mayo  Clinic  from  1933  to  1935. . 
During  World  War  H he  served  for  three  years,  ^ 
1942  to  1945,  at  the  Percy  Jones  General  Hospital! 
in  Battle  Creek,  Michigan,  and  was  separated  fromi 
service  with  the  rank  of  Major.  He  is  a diplomatei 
of  the  American  Board  of  Anesthesiology;  in  1947! 
he  was  President  of  the  American  Society  of  Anes-' 
thesiologists. 

Dr.  Guenther,  a native  of  Omaha,  Nebraska,  re-' 


VOL.  XXI,  NO.  1 


Medical  Annals  of  the  District  of  Columbia 


53 


ceived  his  medical  training  at  the  University  of 
Michigan.  Like  Dr.  Tjiohy,  he  studied  anesthesiol- 
ogy at  the  Mayo  Clinic,  from  1943  to  1945  and  again 
from  1946  to  1947.  He  became  a member  of  the 
Georgetown  staff,  when  the  new  Hospital  w'as 
opened  in  1947,  as  Associate  in  the  Department  of 
Anesthesia. 

Dr.  Winfred  Overholser,  Superintendent  of  St. 
Elizabeths  Hospital,  and  Dr.  Harvey  J.  Tompkins, 
Chief  of  the  Psychiatry  and  Neurology  Division, 
VA  Department  of  Medicine  and  Surgery,  were 
among  the  12  United  States  delegates  to  the  Fourth 
International  Congress  on  Mental  Health,  which 
convened  in  Mexico  City,  December  11-19,  1951. 
The  Chairman  of  the  delegation  was  Dr.  Robert  H. 
Felix,  Director  of  the  National  Institute  of  Mental 
Health,  PHS. 

Colonel  Joe  M.  Blumberg,  MC,  USA,  addressed 
the  Washington  Society  of  Pathologists,  January  10, 
at  the  Army  Medical  Service  Graduate  School, 
Walter  Reed  Army  Medical  Center.  His  subject 
was  “The  Pathogenesis  of  Lung  Carcinoma.”  Other 
speakers  were  Drs.  J.  B.  Horrell  and  John  S.  Howe, 
of  Veterans  Administration  Hospital,  and  Dr.  Lalla 
Iverson,  of  the  Armed  Forces  Institute  of  Pathol- 
ogy- 

Dr.  Murray  M.  Copeland  attended  the  37th  An- 
nual Clinical  Congress  of  the  American  College  of 
Surgeons  in  San  Francisco,  Calif.,  November  5 to 
9.  During  the  meeting  he  participated  in  a panel 
discussion  on  “Nonmalignant  Lesions  of  the  Breast.” 

Dr.  Copeland  attended  the  meetings  of  the 
Southern  Surgical  Association  in  Hot  Springs,  Va., 
December  4-6. 

Dr.  Wallace  M.  Yater,  Theodore  Wiprud,  and  A. 
Louise  Eckburg,  of  the  editorial  staff  of  the  Medi- 
cal Annals,  attended  the  two-day  State  Medical 
Journal  Conference  in  Chicago,  November  12  and 
13.  The  meetings  were  held  at  the  headquarters  of 
the  .American  Medical  Association. 

Dr.  Yater  and  Mr.  Wiprud  participated  in  the 
program.  Dr.  Yater’s  discussion  on  the  make-up  of 
a journal  followed  an  address  on  “The  Job  of  an 
Editor”  by  Dr.  Walter  Kahoe,  Director  of  the 
Medical  Department  of  J.  B.  Lippincott  Comj)any. 


Mr.  Wiprud  was  moderator  during  the  Monday 
afternoon  session.  He  introduced  Mr.  Harry  L. 
Shaw,  General  Editor  of  Harper  and  Brothers,  who 
spoke  on  “Literary  Aspects  of  Medical  Journalism,” 
and  Mr.  Lester  L.  Hawkes,  Associate  Professor  of 
Journalism,  University  of  Wisconsin.  The  latter  dis- 
cussed “Mechanical  Make-up  of  the  Journals.” 

On  Monday  evening,  registrants  at  the  Confer- 
ence were  guests  of  Luziers,  Inc.,  at  a reception  pre- 
ceding dinner  in  the  Walnut  Room  of  the  Bismarck 
Hotel,  where  they  were  guests  of  the  American 
Medical  Association. 

Captain  George  N.  Raines,  MC,  USN,  a Director 
of  the  American  Board  of  Psychiatry  and  Neurology, 
participated  in  the  Board  examinations  which  were 
conducted  in  New  York  City,  December  16-18.  He 
also  attended  the  meetings  of  the  Association  for 
Research  in  Nervous  and  Mental  Diseases  which 
were  held  in  the  same  city  just  prior  to  the  Board 
meetings. 

Mr.  James  G.  Caposella,  Administrator  of  Emer- 
gency Hospital  for  the  past  nine  years,  has  ten- 
dered his  resignation  to  the  Board  of  Directors  of 
the  Hospital,  effective  May  1,  when  his  present 
term  expires.  Mr.  Caposella  came  to  the  Hospital  in 
1938  as  Assistant  Administrator  and  was  named 
Administrator  in  1942. 

Dr.  Walter  Freeman  returned  to  Washington, 
December  15,  after  a fortnight  of  traveling  and 
lecturing  in  Florida,  Cuba,  Curagao  and  Puerto 
Rico.  At  Bay  Pines,  Florida,  he  addressed  the 
Pinellas  County  Medical  Society  on  “Transorbital 
Lobotomy  for  the  Relief  of  Pain.”  In  the  same  city 
he  spoke  on  “Climate  in  Multiple  Sclerosis”  before 
the  medical  staff  of  the  Veterans  Administration 
Hospital. 

He  gave  two  addresses  before  the  Puerto  Rico 
Medical  Society,  one  on  “Transorbital  Lobotomy 
for  the  Relief  of  Physical  and  Mental  Pain”  and 
the  other  on  “Technics  of  Transorbital  Lobotomy.” 
He  lectured  on  the  same  subjects  in  Curacao  and 
Cuba. 

Rear  Admiral  Lament  Pugh,  Surgeon  General  of 
the  Navy,  was  honored  on  December  1 in  cere- 
monies held  at  Wagner  College,  Staten  Island,  New 
York,  when  the  College  bestowed  upon  him  the 


54 


Woman's  Auxiliary  Notes 


JANUARY,  1952 


lionorarv  degree  of  Doctor  of  Laws.  Following  the 
ceremonies  the  Surgeon  General  and  his  party  at- 
tended a dinner  given  by  the  President  of  the  Col- 
lege and  his  wife,  Dr.  and  Mrs.  \\’aiter  Consuelo 
Langsam. 

Dr.  Frederick  J.  Balsam  has  been  made  .Assistant 
Chief  in  the  Department  of  Physical  Medicine  and 
Rehabilitation  at  the  Kennedy  General  Hospital  in 
Memphis,  d'enn.  He  has  also  been  api)ointed  to  the 
Editorial  Board  of  the  Journal  of  the  .Association 
for  Physical  and  Mental  Rehabilitation. 

Dr.  Daniel  L.  Seckinger,  District  Health  Direc- 
tor, will  head  solicitation  in  the  District  Govern- 
ment for  the  1951-52  fund  drive  of  the  Arthritis 
and  Rheumatism  Foundation.  The  Foundation  is 
seeking  50,(100  new  members  for  the  District  Chap- 
ter. 

Word  of  some  new  assignments  and  activities  of 
Medical  Society  members  in  service  has  reached  the 
Executive  Offices. 

Colonel  John  F.  Dominick,  MC,  USAF,  has  been 
assigned  to  headquarters  of  the  U.  S.  Air  Force  in 
Europe,  where  he  will  be  Chief  of  the  Professional 
Services  Division.  His  former  duties  as  Chief  of  the 
Medical  Consultants  Division  for  the  Office  of  the 
-Air  Force  Surgeon  General  have  been  assumed  by 
Colonel  Oscar  S.  Reeder. 

Colonel  William  H.  Beard,  MC,  USAF,  is  now 
stationed  at  Newcastle  County  .Airport,  Wilming- 
ton, Delaware.  Colonel  Beard  was  called  back  into 
service  on  I’ebruary  1,  1951,  and  has  served  in  Cen- 
tral .America  and  the  Caribbean  .Area. 

Lt.  Colonel  Francis  D.  Threadgill,  MC,  USA,  is 
jwesently  stationed  at  Fort  Ord,  California,  and 
assigned  to  the  Orthopedic  Section. 

Major  Brooks  G.  Brown,  MC,  USA,  visited  the 
.Society’s  offices  on  December  19.  He  was  home  for 
the  Christmas  holidays  and  has  returned  to  duty 
with  the  582nd  General  Hosjiital  in  Japan. 

Captain  A.  Jacobson,  MC,  USA,  has  been  assigned 
to  overseas  duty.  He  is  Chief  of  the  Neuropsychiatric 
.Ser\  ice  of  the  141st  General  Hospital. 

Dr.  Lucian  Bauman  was  recently  certitied  by  the 
.American  Board  of  Ophthalmology. 


Dr.  Frederick  D.  Mott,  who  has  served  as  Deputy 
Minister  of  Public  Health  of  Ji'anada,  with  offices  in 
Regina,  Saskatchewan,  has  returned  to  \\'ashing- 
ton;  his  offices  are  located  at  1427  Eye  Street,  N.W. 

Dr.  Charles  H.  Nash,  Jr.  has  moved  to  Lubbock, 
Te.xas,  where  he  is  practicing  at  1518  Main  Street. 
Wdiile  in  \\'ashington  Dr.  Nash  was  Chief  Medical 
Officer  in  the  Department  of  Obstetrics  and  Gyne- 
cology at  Gallinger  Municipal  Hospital. 

Dr.  R.  Stevens  Pendexter  has  sent  the  Secretary 
of  the  Medical  Society  a new  address,  9 Lejeune 
Court,  Old  Greenwich,  Conn. 

WOMAN’S  AUXILIARY  NOTES 

The  Eighth  .Annual  Conference  of  State  Presi- 
dents, Presidents-elect,  and  National  Committee 
Chairmen  of  the  Woman’s  .Auxiliary  to  the  .American 
Medical  .Association  was  held  in  Chicago  at  the 
Hotel  LaSalle  on  November  14  and  15.  Included  in 
the  plan  of  the  Conference  were  nine  panel  discus- 
sions, for  which  the  National  Chairmen  were  Mod- 
erators and  State  Presidents,  participants. 

Mrs.  Edgar  E.  (Juayle,  National  Legislation 
Chairman,  was  moderator  for  the  panel  discussion 
on  “Legislation  and  .Americanism.”  The  moderators 
were  responsible  for  the  panels,  which  proved  most 
interesting  and  informative. 

Mrs.  Richard  E.  Dunkley  was  assigned  to  the 
Finance  Committee  Panel  and  spoke  on  “The  Im- 
portance of  Records — the  Financial  Record  System 
for  a State  .Auxiliary.” 

The  Woman’s  .Auxiliary  as  a local  group  has  had 
a full  calendar  this  past  half-year.  Flach  week  has 
been  filled  with  varied  activities  of  work  and  rec- 
reation. 

The  standing  and  special  committees  have  been 
in  full  swing  and  have  presented  extremely  interest- 
ing programs. 

Ihider  the  chairmanship  of  Mrs.  Jonathan  M. 
\\'illiams,  the  Educational  Committee  is  handling 
for  the  .Auxiliary  the  financial  aid  for  nurses’  training. 
Currently,  there  are  two  trainees  at  Gallinger  Mu- 
nicipal Hospital  and  two  at  Garfield  Memorial  Hos- 
{)ital  receiving  this  help. 

The  Philanthropic  Committee,  under  the  chair- 


VOL.  XXI,  NO.  1 


Medical  Annals  of  the  District  of  C otumbia 


55 


manship  of  Mrs.  W.  Bryan  Orr,  has  maintained  a 
booth  for  the  sale  of  Tuberculosis  Christmas  Seals. 

Mrs.  Richard  H.  Todd,  Chairman  of  the  Public 
Relations  Committee,  is  outlining  with  the  Civil 
Defense  Committee  of  the  District  of  Columbia  the 
role  of  the  Auxiliary  during  Civil  Defense  Week, 
which  will  be  held  early  in  1952.  A guest  speaker 
will  address  the  Auxiliary  on  this  subject  at  its 
regular  meeting  in  January. 

The  Ways  and  Means  Committee,  Mrs.  John  E. 
Morris,  Chairman,  has  plans  for  a spring  dance. 
The  proceeds  from  this  dance  will  be  used  for  an 
educational  project  next  year. 

Mrs.  Lawrence  A.  Rapee  reports  that  the 
Membership  Committee  will  sponsor  a tea  for  new 
members  to  be  held  in  January. 

The  House  Committee,  Mrs.  How^ard  A.  Donald, 
Chairman,  has  served  tasty  and  attractive  luncheons 
following  the  regular  meetings.  The  Christmas  deco- 
rations for  the  December  meeting  were  unusually 
lovely. 

A special  committee  under  Mrs.  Harry  Lewds  has 
hung  new  curtains  in  the  library. 

The  activities  of  the  Social  Committee,  Mrs.  M. 
Noel  Stow,  Chairman,  have  covered  a wide  range 


of  interests.  The  Bowling  League,  under  Mrs.  Duane 
Richtmeyer,  meets  weekly.  Twelve  teams  made  up 
of  60  members  are  competing  in  a tournament  which 
will  end  in  the  spring. 

Mrs.  Francis  J.  O’Bryan  made  arrangements  for 
the  Spanish  lessons  which  are  conducted  w'eekly; 
Mrs.  Robert  Taylor,  for  classes  in  Latin  American 
dances;  and  Mrs.  Leo  Varden,  for  bridge  lessons. 

Mmes.  Joseph  Bailey,  David  Nolan,  William 
Moses  and  Charles  Jones  will  assist  the  Social  Chair- 
man, Mrs.  Stow,  on  plans  for  further  activities  in 
the  spring.  Courses  in  flower  arrangement  and  self- 
improvement  are  anticipated. 

Each  regular  meeting  has  had  interesting  speakers. 
These  programs  have  been  the  responsibility  of  Mrs. 
Herbert  H.  Schoenfeld. 

Mrs.  Samuel  A.  .'Mexander,  National  Convention 
Delegate,  accompanied  her  husband  on  a trip  to 
Honolulu  to  the  triennial  meeting  of  the  Pan  Pacific 
Surgical  .Association  Congress,  November  7-19. 
While  there  she  was  invited  to  attend  a meeting 
and  luncheon  of  the  Executive  Board  of  the 
Auxiliary. 

Mrs.  Al.\n  F'r.a.nk  Kreglow 
Pubticily  Chairman 


BOOK  REVIEWS 


The  Battle  of  the  Conscience;  A Psychiatric 
Study  of  the  Inner  Working  of  the  Conscience. 
Edmund  Bergler,  M.D.  Price,  S.C7.r  Pp.  296.  Wash- 
ington, D.  C.:  Washington  Institute  of  Medicine,  1948. 

Taking  for  his  thesis  the  belief  that  “everyone  has  an 
inner  conscience  and  is  constantly  under  the  influence  of 
that  inner  department  of  the  personality,”  Bergler  dis- 
cusses, in  16  chapters,  the  various  aspects  of  conscience 
and  the  many  manifestations  of  neurotic  guilt.  He 
divides  the  Super  Ego  into  two  parts,  the  Ego  Ideal  and 
the  Daimonion,  borrowing  the  latter  term  from  Socrates, 
and  identifying  the  Daimonion  with  the  “Thou  shall 
not”  attitude  of  the  Super  Ego  as  contrasted  with  the 
“Thou  shall”  attitude  of  the  Ego  Ideal.  Using  a legal 
figure,  he  compares  the  Id  to  the  accused,  the  Ego  to  an 
attorney  for  the  defense,  and  the  Sut)er  Ego  to  a District 
.Attorney  or  Prosecutor,  the  whole  j)rocess  being  coordi- 
nated with  Freud’s  Eros-'I'hanatos  theory  the  op[)osi- 
tion  of  the  life  and  the  death  instincts.  He  carries  this 
legal  figure  into  his  discussion  of  normal  and  neurotic 
inner  feeling  of  guilt,  using  numerous  clinical  examples, 
and  sets  out  schematically  a nine-point  differentiation 


between  normal  and  neurotic  aggression — since  aggres- 
sion is  one  of  the  most  frequent  guilt-producing  factors — 
with  illustrative  textual  comment  and  examples. 

.A  chapter  on  typical  examples  of  neurotic  guilt  is  fol- 
lowed by  one  on  what  the  author  calls  the  “Injustice 
Collectors,”  which  is  concerned  with  neurotics’  constant 
unconscious  construction  of  situations  in  which  they  are 
disappointed  and  “mistreated,”  and  which  involves  what 
he  terms  the  “mechanism  of  orality,”  a concept  of  his 
own  by  which  he  traces  the  genesis  of  the  largest  part  of 
neurotic  conflict  to  the  oral  phase  of  infantile  develop- 
ment. 

Normal  antidotes  for  guilt  are  discussed  under  the 
headings  of  'Fender  Love,  Work,  Sublimation,  Rational- 
ization, and  what  the  author  calls  “Pathos,”  a term 
borrowed  from  the  (Ireek  and  which  “has  no  connection 
with  the  usual  connotation  of  [)ity.”  With  respect  to 
Sublimation,  he  describes  a five-layer  process  of  psychic 
impulse  and  reaction,  only  the  fifth  layer  rei)resenting 
the  culmination  of  conflict  in  the  sublimating  activity. 
Several  clinical  illustrations  of  this  ])rocess  are  given. 
Contrasted  with  these  normal  ant  idotes  for  guilt  are  the 


56 


Book  Reviewv 


JANUARY,  1952 


neurotic  ones,  Cynicism,  Hypocrisy,  and  Self-Derision, 
likewise  illustrated  by  numerous  clinical  examples.  Sep- 
arate chapters  are  devoted  to  the  relation  between  Iden- 
tification and  Inner  Guilt;  to  depression  following  upon 
success,  which  involves  conflicts  with  conscience;  and  to 
several  other  manifestations  of  unconscious  guilt,  includ- 
ing dreams  and  insomnia. 

The  relation  between  unconscious  guilt  and  criminal 
activity  is  the  subject  of  a long  chapter  in  which  Bergler 
compares  the  “Mechanism  of  Orality  in  Neurosis”  with 
the  “Mechanism  of  Criminosis.”  This  chapter  also  con- 
tains references  to  and  comments  on  the  work  of  several 
other  psychoanalysts  who  have  concerned  themselves 
with  the  study  of  crime. 

The  volume  cannot  fail  to  be  a revelation  to  the  in- 
dividual who  thinks  of  guilt  and  conscience  as  compara- 
tively simple  matters,  for  the  author  has  demonstrated 
convincingly  their  diversity,  complexity,  and  many  un- 
suspected ramifications.  Like  many  analysts  who  postu- 
late a pet  theory,  he  appears  to  be  somewhat  dogmatic 
where  the  “mechanism  of  orality”  is  concerned,  attribut- 
ing to  it  a universality  which  many  other  authorities  may 
be  disinclined  to  accept;  but  his  approach  is  invariably 
constructive  and  humanitarian,  and  the  book  is  almost 
equally  productive  of  stimulating  thought  for  both  the 
psychiatrist  and  the  lay  worker.  It  is  to  be  regretted, 
however,  that  a work  which  deals  with  so  many  aspects 
of  a single  subject  has  not  been  provided  with  an  index. 

Valentine  Ujhely,  M.D. 

Investments  for  Professional  People.  Robert  U. 
Cooper,  B.P.E.,  M.A.,  M.D.  Price,  $4.00.  Pp.  342.  New 
York:  Macmillan,  1951. 

The  author  is  a physician  who  has  written  this  book 
primarily  for  the  members  of  his  own  profession,  although 
he  states  that  there  are  many  problems  common  to  all 
professional  people.  It  is  of  great  value  to  the  profes- 
sional man  at  any  stage  of  his  career,  but  most  especially 
to  the  interns  and  residents.  Hence  this  book  should  be 
available  to  the  house  staffs  of  all  hospitals  and  should 
be  in  the  libraries  of  medical  schools  and  physicians. 

The  first  half  of  the  book  is  valuable  to  an  individual 
who  is  just  beginning  his  professional  career.  In  the  most 
simple  and  positive  language,  the  author  discusses  the 
location  of  an  office,  its  equipment  and  personnel,  and 
the  importance  of  keeping  accurate  financial  records.  He 
takes  up  the  troublesome  problem  of  ascertaining  ap- 
propriate and  just  fees.  He  demonstrates  himself  superb 
at  simplifying  and  making  readable  the  rules  and  regula- 
tions regarding  the  income  tax.  He  emphasizes  repeatedly 
the  importance  of  keeping  accurate  records  and  being 
familiar  with  the  legal  definitions  of  income  and  of  per- 
missible deductions.  He  contends  that  every  physician 


should  be  able  to  fill  out  his  own  income  tax  returns 
because  he  is  held  responsible  regardless  of  assistance. 

The  author  treats  the  insurance  problem  in  a most 
rational  manner.  He  demonstrates  the  necessity  of  in- 
surance during  the  early  part  of  one’s  career  to  afford 
adequate  security.  He  insists  that  the  professional  man 
should  utilize  his  own  analytical  ability  that  his  business 
endeavors  may  be  adjusted  to  his  own  needs.  He  is 
aware  that  the  young  physician  has  spent  many  years 
and  much  effort  to  acquire  his  profession,  and  that  he 
has  become  accustomed  to  accepting  the  statements  of 
medical  authorities.  He  emphasizes  that  this  attitude 
should  never  be  adopted  in  the  business  world,  because 
every  salesman  is  apt  to  benefit  by  the  proposed  business 
transaction  and  therefore  he  might  be  biased  in  his 
eagerness  to  make  the  sale.  Furthermore,  the  salesman 
may  not  be  familiar  with  or  conscientious  regarding  the 
requirements  of  the  professional  man. 

The  author  defines  the  advantages  of  banking  facili- 
ties, and  urges  that  the  physician  take  advantage  of  the 
various  consultation  services. 

The  first  4 chapters  of  the  book  constitute  primarily 
a primer  to  aid  the  readers  to  understand  the  problems 
inherent  to  professional  careers.  The  last  7 chapters  are 
dedicated  to  the  more  secure  and  successful  professional 
man.  In  the  latter  part  of  the  book  the  author  assumes 
that  the  individual  has  been  successful  and  has  surplus 
money  for  investments.  He  discusses  the  characteristics 
affecting  the  value  of  real  estate  and  suggests  a scientific 
method  of  appraisal.  He  indicates  that  few  physicians 
have  the  experience  to  become  acquainted  with  real 
estate  and  therefore  they  must  depend  to  a large  extent 
upon  consultants,  but  he  does  give  a formula  for  inspec- 
tion and  for  determining  approximate  values. 

One  of  the  most  instructive  parts  of  the  book  con- 
sists of  analysis  of  financial  statements.  He  contends  that 
every  professional  man  has  the  ability  to  analyze  a finan- 
cial statement  and  should  take  the  time  to  do  so.  He 
forms  a hypothetical  company  and  develops  the  financial 
statements  during  the  various  periods  of  its  growth. 

The  author  has  defined  bonds,  preferred  stocks,  and 
common  stocks.  He  has  pointed  out  the  relative  merits 
of  each.  He  has  attempted  to  familiarize  the  reader  with 
investment  funds  and  with  special  investment  oppor- 
tunities, including  the  hazards  of  a professional  man  to 
own  a farm,  especially  if  his  only  qualifications  consist 
of  adequate  funds  to  make  the  purchase 

He  emphasizes  the  importance  of  making  a will.  He 
points  out  the  value  of  distributing  an  estate  in  part 
during  life. 

The  last  section  of  the  book  deals  with  the  invest- 
ment program  and  constitutes  a challenge  to  the  reader 
to  analyze  himself.  He  thinks  that  if  an  individual  can- 


VOL.  XXI,  NO.  1 


Medical  Annals  of  the  District  of  Columbia 


57 


, not  take  risks  without  a mental  hazard,  then  he  should 
invest  his  money  more  securely,  such  as  in  Government 
bonds. 

Dr.  Cooper  has  demonstrated  a rare  ability  to  make 
problems  attractive  and  to  use  simple  but  forceful  lan- 
guage. This  book  represents  excellent  reading.  The 
author  has  intended  that  this  book  should  be  merely  an 
introduction  to  the  problems  of  investment;  he  has 
attempted  to  stimulate  the  professional  man  to  think  in 
terms  of  making  investments  with  intelligence  and  with- 
out emotion.  This  book  will  certainly  broaden  the  horizon 
of  the  business  knowledge  of  any  physician  who  cares  to 
read  it.  This  reader  regrets  that  this  book  was  not  avail- 
able to  him  20  years  ago.  He  feels  sure  that  had  this 
been  the  case,  he  would  have  avoided  some  poor  invest- 
ments. Dr.  Cooper  has  responded  to  a great  need  that 
exists  among  professional  people,  and  his  book  merits 
many  editions. 

0.  Hugh  Fulcher,  M.D. 

CORRESPONDENCE 

Chicago,  Illinois,  November  27,  1951 

To  THE  Editor: 

In  the  October  issue  of  Medical  Annals  of  the  District 
of  Columbia,  on  page  558,  there  appears  a statement  to 
the  effect  that  “at  least  one  Blue  Shield  Plan  is  now 
underwritten  by  several  large  insurance  companies.” 

I believe  you  will  find  this  statement  to  be  in  error, 
because  none  of  the  Blue  Shield  Plans  are  so  under- 
written. 

One  of  the  strictly  enforced  Membership  Standards 
of  this  organization,  to  which  Blue  Shield  Plans  belong, 
is  the  requirement  that  each  plan  be  operated  on  a non- 
profit basis.  If  a plan  were  to  be  underwritten  by  a com- 
mercial insurance  company,  this  would  constitute  a vio- 
lation of  that  standard. 

Therefore,  your  statement  seems  to  be  in  error,  and  I 
would  appreciate  your  calling  this  to  the  attention  of 
your  readers. 

Sincerely  yours, 

Frank  E.  Smith 

Director,  Blue  Shield  Medical  Care  Flans 
The  Observer’s  Reply: 

Mr.  Smith  is  right  and  Y.O.  stands  corrected.  Wis- 
consin has  two  prepayment  plans:  one,  the  State  Medi- 
cal Society’s  Wisconsin  Plan,  which  utilizes  [irivate 
I insurance  companies;  the  other,  the  Wisconsin  Physi- 
cians’ Service,  also  sponsored  and  approved  by  the  State 
Medical  Society,  a Blue  Shield  Plan.  The  error  occurred 
j because  Y.O.  thought  of  the  two  plans  as  one. 


BOOKS  RECEIVED 

Acknowledgment  is  made  of  the  following  books 
which  have  recently  been  received.  Selections  will 
be  made  for  more  extensive  review  in  the  interests 
of  our  readers  and  as  space  permits.  Physicians  are 
urged  to  submit  reviews  of  additional  current  books 
which,  in  their  opinion,  merit  comment. 

Plastic  Surgery  of  the  Nose  Including  Recon- 
struction of  War  Injuries  and  of  Deformities  from 
Neoplastic,  Traumatic,  Radiation,  Congenital,  and 
Other  Causes.  James  Barrett  Brown,  M.D.,  Profes- 
sor of  Clinical  Surgery,  Washington  University  School  of 
Medicine,  St.  Louis,  Mo.;  Chief  Consultant  in  Plastic 
Surgery,  United  States  Veterans  Administration,  Wash- 
ington, D.  C.;  formerly  Senior  Consultant  in  Plastic 
Surgery,  United  States  Army  and  in  E.T.O.,  and  Chief 
of  Plastic  Surgery,  Valley  Forge  General  Hospital,  and 
Frank  McDowell,  M.D.,  Assistant  Professor  of  Clinical 
Surgery,  Washington  University  School  of  Medicine,  St. 
Louis,  Mo.  Price,  $15.00.  Pp.  427,  with  379  illustrations, 
including  48  in  color.  St.  Louis,  Mo.:  Mosby,  1951. 

Untoward  Reactions  of  Cortisone  and  ACTH, 

A Monograph  in  American  Lectures  in  Internal  Med- 
icine. Vincent  J.  Derbes,  M.D.,  F.A.C.P.,  Associate 
Professor  of  Medicine,  Tulane  University  of  Louisiana 
School  of  Medicine;  Head  of  Department  of  Allergy, 
Ochsner  Clinic;  Visiting  Physician,  Charity  Hospital  of 
Louisiana  at  New  Orleans;  and  Staff  Member,  Founda- 
tion Hospital,  New  Orleans,  Louisiana,  and  Thomas  E. 
Weiss,  M.D.,  Instructor  in  Medicine,  Tulane  University 
of  Louisiana  School  of  Medicine;  Member  of  Department 
of  Medicine,  Ochsner  Clinic;  Visiting  Physician,  Charity 
Hospital  of  Louisiana  at  New  Orleans;  and  Staff  Mem- 
ber, Foundation  Hospital,  New  Orleans,  Louisiana. 
Edited  by  Roscoe  L.  Pullen,  M.D.,  Director,  Division 
of  Graduate  Medicine,  The  Tulane  University  of  Loui- 
siana, New  Orleans,  Louisiana.  Price,  $2.25.  Pp.  77. 
Springfield,  III.:  Thomas,  1951. 

Biolog  cal  Antagonism,  The  Theory  of  Bio- 
logical Relativity.  Gustav  J.  Martin,  Sc.D.,  Re- 
search Director,  'I'he  National  Drug  Co.,  Philadelphia, 
Pa.  Price,  $8.50.  Pji.  516,  with  64  figures  and  44  tables. 
New  York  & Philadelphia:  Blakiston,  1951. 

The  Rockefeller  Foundation  Directory  of  Fel- 
lowship Awards  for  the  Years  1917-1950.  I'he  Rocke- 
feller Foundation,  with  an  Introduction  by  Chester  1. 
Barnard,  President  of  the  Foundation.  Pp.  286.  New 
York:  'I’lic  Rockefeller  Foundation,  1951. 


Obituaries 


JANUARY,  1952 


5cS 

Annual  Report  on  Stress.  Hans  Selye,  M.U., 
Ph.1).  (Prague),  I). Sc.  (McGill),  F.R.S.  (Canada),  Pro- 
fessor and  Director  of  the  Institut  de  Medecine  et  de 
Chirurgie  experimentales,  Universite  de  Montreal.  Price, 
SlO.OO.  Pp.  644,  with  illustrations.  Montreal,  Canada: 
Acta,  Inc.,  1951. 

Textbook  of  Refraction.  Edwin  Forbes  J'ait, 
M.I).,  Ph.D.,  Associate  Professor  of  Ophthalmology, 
Temple  University  School  of  Medicine;  .\ttending  Sur- 
geon (Ophthalmology),  Temple  University  and  Mont- 
gomery Hospitals;  Fellow,  Philadelphia  College  of  Phy- 
sicians, and  .American  .Academy  of  Ophthalmology  and 
Otolaryngology;  Member,  The  Pan-American  .Associa- 
tion of  Ophthalmology,  and  The  Association  for  Research 
in  Ophthalmology.  Price,  S8.()0.  Pp.  418,  with  93  figures. 
Philadelphia:  Saunders,  1951. 


CHARLES  MIDDLETON  BEALL,  M.D. 
(1877-1951) 

An  Appreciation 

His  life  was  gentle,  and  the  elements 
So  mix’d  in  him,  that  Nature  might  stand  uj) 

■And  say  to  all  the  world,  “This  was  a man!” 

A man  and  a gentleman — that  was  Dr.  Charles 
Middleton  Beall.  He  was  not  showy  or  spectacular; 
but  that  did  not  detract  from  his  worth.  He  was 
quiet,  unassuming,  unobtrusive,  dignified;  but  never- 
theless he  was  a man  of  firmness  and  force,  thor- 
oughly honorable  and  dependable,  as  substantial 
and  strong  as  the  Rock  of  Dumbarton,  the  toponym 
of  his  race.  His  life  was  really  gentle;  he  was  genial 
and  comjtanionable,  and  he  faced  the  world  with 
quiet  humor.  His  character  and  personality  endeared 
him  to  his  friends,  and  won  for  him  general  esteem 
and  ajtpreciation.  Daily  association  with  him  for 
thirty  years  inspired  keen  affection.  Such  as  he  are 
the  type  of  the  ideal  physician,  earning  the  gratitude 
and  admiration  of  the  community  for  able,  faithful, 
and  selfless  service  in  its  behalf,  the  type  in  which 
physicians  take  pride  and  which  establishes  the  spirit 
and  idealism  of  the  medical  profession. 

Dr.  Beall  was  not  only  a native  and  lifelong 
resident  of  the  District  of  Columbia,  but  his  ances- 
tral roots  extended  clear  back  through  that  region 
to  the  beginnings  of  its  colonial  historv.  The  original 


progenitor  of  the  family  was  Colonel  Xinian  Beall ■ 
(1625-1717),  a famous  and  colorful  figure  who  was  ' 
one  of  the  principal  founders  of  the  province  of 
Maryland.  A Scottish  soldier  in  the  Royalist  army 
which  was  defeated  by  Cromwell  at  the  battle  of 
Dunbar,  he  was  transported  to  Maryland  about 
1655,  and  there  attained  high  and  active  position  in 
the  service  of  the  [)rovince,  notably  commander-in- 
chief of  the  provincial  military  forces,  member  of  , 
the  Assembly,  successful  negotiator  with  the  Indian 
tribes.  He  acquired  ownership  of  many  large  tracts 
of  land,  aggregating  more  than  25,000  acres,  and 
including  795  acres  styled  the  “Rock  of  Dumbarton” 
on  which  the  city  of  Georgetown  was  subsequently 
established.  He  had  a host  of  descendants,  estimated  J 
at  70,000  in  number,  and  including  four  governors  1 
of  Maryland.  1 

Born  September  22,  1877,  Dr.  Beall  was  the  son  of  j 
Charles  B.  Beall,  deputy  clerk  of  the  United  States  I 
Supreme  Court,  and  Adelaide  Ricketts  Beall;  and 
he  was  first  cousin  of  the  brothers  Drs.  D.  Olin 
Leech  and  Frank  Leech,  prominent  and  popular 
physicians  of  Washington.  He  was  educated  in  the 
C'olumbian  Preparatory  School  and  the  Columbian 
Medical  School  (now  the  George  Washington  Uni- 
versity), from  which  he  graduated  in  1900  with  the 
degree  of  Doctor  of  Medicine.  In  his  youth  Dr. 
Beall  was  a famous  baseball  player,  and  his  prowess  j 
in  that  sport  is  still  remembered.  In  selecting  his  life  I 
career  he  considered  three  possibilities,  professional  i 
baseball,  a job  in  the  X'aval  Gun  Factory,  and 
medicine.  In  the  profession  which  he  wisely  selected 
he  engaged  with  ability  and  success.  In  addition  to  | 
active  private  practice,  he  served  as  inspector  in  the  j 
District  Health  Department,  a member  of  the  staff 
of  Garfield  Memorial  Hosi)ital,  and  from  1920  as  ■ 
.Assistant  Medical  Director  of  Acacia  Mutual  Life 
Insurance  Company.  In  all  these  fields  he  manifested 
marked  ability,  reliability,  and  wise  judgment. 

Dr.  Beall’s  latter  years  were  full  of  illness,  mis- 
fortune, and  tragedy,  domestic  and  personal.  His 
wife  died  as  a result  of  injuries  incurred  in  saving  the 
life  of  a child  in  an  automobile  accident.  His  young 
grandchild  died  suddenly  and  unexpectedly.  There 
was  protracted  and  serious  illness  in  his  family. 
From  1944  Dr.  Beall  himself  was  a victim  of  leu- 
kemia, with  prolonged  and  intense  sufferings  and 
prostration.  In  spite  of  his  distressing  and  disabling  | 
symptoms,  however,  he  insisted  on  continuing  his  .1 


Medical  Annals  of  the  District  of  Columbia 


59 


VOL.  XXI,  NO.  1 

\ 

accustomed  daily  duties  and  activities  with  a spirit, 
persistence,  and  energy  which  were  the  amazement 
and  admiration  of  his  friends.  Dr.  Beall’s  death,  on 
November  20,  1951,  was  euthanasia,  a merciful  re- 
lease from  suffering. 

John  B.  Nichols,  M.D. 

CUSTIS  LEE  HALL,  M.D., 
F.A.C.S.,  F.LC.S. 

(1888-1951) 

A Tribute 

“We  of  the  Washington  Orthopedic  Club 
mourn  the  loss  of  our  internationally  famous 
member  and  president,  but  we  feel  profoundly 
, grateful  for  having  had  the  privilege  of  knowing 
this  great  man.  . . . He  will  remain  forever  in  our 
! memories,  not  alone  as  a distinguished  physician 
and  educator,  but,  above  all,  as  a friend  and 
counsellor.” 


Dr.  Custis  Lee  Hall,  internationally  known  Wash- 
ington orthopedic  surgeon,  died  on  Saturday, 
November  10,  1951,  at  Doctors  Hospital  following 
a brief  illness. 

Dr.  Hall  was  born  in  Washington,  D.  C.,  July  15, 
1888.  He  received  his  early  education  in  the  public 
schools  of  the  Nation’s  Capital  and  graduated  from 
George  Washington  University  School  of  Medicine 
in  1912.  Internships  followed  at  Garfield  Memorial 
and  George  Washington  University  hospitals,  with 
a residency  in  orthopedics  at  Massachusetts  General 
Hospital,  Boston. 

Dr.  Hall  served  with  the  British  and  .American 
Expeditionary  Forces  in  World  War  I.  He  was  a 
: Major  in  the  Medical  Corps  of  the  United  States 
Army  when  he  returned  to  Washington.  He  imme- 
diately entered  private  practice,  specializing  in  or- 
thopedics. As  the  years  passed  his  prestige  grew 
among  the  medical  profession  and  he  became  one 
of  the  best  known  orthopedic  surgeons  in  the  United 
States. 

He  was  Chief  of  the  Division  of  Orthopedic  Sur- 
gery at  Doctors  Hosjiital  from  1941  until  his  death. 
He  held  a similar  post  at  Garfield  Memorial  Hos[)ital 
and  was  a consultant  at  Mt.  Alto  Veterans  Ad- 
ministration Hospital.  For  the  past  .15  years  he  had 
been  orthopedic  surgeon  on  the  staff  of  ('hildren’s 
Hospital. 


Dr.  Hall  had  long  been  a member  of  the  faculty 
at  George  Washington  School  of  Medicine.  He  was 
Professor  of  Orthopedic  Surgery  from  1920  to  19.H 
and  Clinical  Professor  of  Surgery  from  19,H  to  the 
present  time. 

.\lways  deeply  interested  in  medical  organization, 
he  was  an  active  and  interested  member  of  the 
Medical  Society  of  the  District  of  Columbia  from 
the  time  of  his  election  in  1917.  He  served  on  various 
committees  and  was  First  Vice  President  of  the 
Society  in  1943  44.  He  was  President  of  the  Ambu- 


CUSTIS  lef:  H.VLL,  M.D. 


latory  Fracture  Association  in  1938.  In  the  same 
year  he  became  President  of  the  United  States  Chap- 
ter of  the  International  College  of  Surgeons.  At  the 
time  of  his  death  he  was  V'ice  President  of  the 
International  College  of  Surgeons  and  President  of 
the  Washington  Orthopedic  Club. 

Dr.  Hall  was  a diplomate  of  the  American  Board 
of  Orthopedic  Surgery;  a Fellow  of  the  American 
Medical  Association  and  the  American  ('ollege  of 
Surgeons;  a member  of  the  Washington  Academy 
of  Surgery,  the  Washington  Academy  of  Medicine, 
the  American  Academy  of  Orthopedic  Surgeons,  the 
Pan  American  Medical  Society,  the  Southern  Medi- 
cal .Association,  the  Southeastern  Surgical  Society, 
and  the  .American  'rhcra])eutic  Society. 


f 


60 


Medical  Annals  of  the  District  of  Columbia 


JANUARY,  1952 


Among  his  other  affiliations  were  memberships  in 
the  Smith-Reed-Russell  Society  of  George  Washing- 
ton University,  Sigma  Xi  fraternity,  the  Army  and 
Navy  Club,  the  Columbia  Country  Club,  the 
Kivvanis  Club,  and  the  Seigniry  Club  (Canada).  He 
was  a Mason,  a Knight  Templar,  and  a Shriner. 

Perhaps  none  of  his  professional  activities  received 
wider  public  recognition  than  the  medical  treatment 
he  provided  crippled  children  under  the  sponsorship 
of  the  Underprivileged  Child  Committee  of  the  Ki- 
wanis  Club.  In  1936  he  was  presented  the  Washing- 
ton Times  Award  for  outstanding  service  to  the 
people  of  the  District  of  Columbia.  The  award  was 
presented  to  him  by  the  then  District  Commissioner 
Melvin  C.  Hazen. 

Dr.  Hall  is  survived  by  his  wife,  Mrs.  Mary 
Golden  Hall;  a son,  Custis  Lee  Hall,  Jr.;  and  two 
daughters.  Miss  Elizabeth  Hall  and  Miss  Nancy 
Hall,  all  of  3920  Harrison  Street,  N.  W.  Another 
daughter,  Mrs.  Thomas  Klein,  of  Rosemont,  Penn- 
sylvania, and  a sister,  Mrs.  C.  F.  Haynsworth,  of 
Greenville,  South  Carolina,  also  survive  him. 


El  ectrophoresis — Reiner 


20.  Silver,  S.,  and  Reiner,  M.:  Bull.  New  York  Acad.  Med.,” 

1950,  26,  277. 

21.  Sterling,  K.;  Bull.  New  England  M.  Center,  1951,  13, 

121. 

“That  Full  Feeling” — Gibb 

{Continued  from  page  22) 

to  if  the  circumstances  prevailing  were  entirely 
to  their  liking.  Reassurance,  patience,  simple 
medication  of  the  so-called  antispasmodic  vari- 
ety, and  a sensible,  well  balanced  diet  will  do  ■ 
wonders. 

In  summary,  this  sensation  of  fullness  and  . 
satiety  after  a few  bites  is  usually  purely  func- 
tional in  origin.  It  is  a real,  not  an  imagined 
feeling,  and  is  caused  by  the  tonus  of  the  body  of 
the  stomach  not  decreasing  when  food  enters  the 
fundus.  Food  remains  in  the  fundus  and  slightly 
overdistends  it,  thereby  doing  away  with  the  feel- 
ing of  hunger.  The  tonus  of  the  body  and  that 
of  the  fundus  are  different,  being  less  in  the  latter. 

Perforation  of  Fish  Bone  into  Portal  Vein-Widome 

{Continued  from  page  25) 

Comment 


{Continued  from  page  16) 

17.  Pauling,  L.,  Itano,  H.  Singer,  S.  J.,  and  Wells, 

I.  C.:  Ibid.,  1949,  110,  543. 

18.  Stern,  K.  G.,  Reiner,  M.,  and  Silber,  R.  H.:  J.  Biol. 

Chem.,  1945,  161,  731. 

19.  Fenichel,  R.  L.,  Watson,  J.,  .and  Eiricii,  F.  : J.  Clin. 

Investigation,  1950,  29,  1620. 


Apparently  the  cause  of  this  patient’s  initial 
pain,  a month  prior  to  admission  was  the  ffsh 
bone  in  the  act  of  perforating  or  embedding  itself 
in  the  wall  of  the  duodenum.  The  septic  course 
was  brought  on  following  actual  perforation  into 
the  portal  vein. 


MEDICAL  ANNALS 

of  the 

DISTRICT  OF  COLUMBIA 


VOLUME  XXI  February,  1952  NUMBER  2 


THE  CANCER  PROBLEM* 


C WELCOME  the  opportunity  which 

this  occasion  provides  to  thank  you  for  the  honor 
you  have  done  me  in  inviting  me  to  address  your 
Society. 

I sail  for  England  toward  the  end  of  No- 
vember, and  by  that  time  I shall  be  one  of  many 
Englishmen  who  have  been  privileged  to  study 
without  let  or  hindrance  the  general  pattern  and 
purpose  of  North  American  civilization.  I shall 
have  enjoyed  your  warm  hospitality,  and  I sin- 
cerely hope  1 shall  have  been  able  in  some  small 
measure  to  strengthen  the  links  which  bind  our 
two  nations  together. 

I should  like  to  talk  to  you  today  about  cancer 
research,  which  has  two  distinct  aspects,  clinical 
and  experimental. 

With  regard  to  the  first,  1 would  be  insulting 
your  intelligence  if  1 attempted  to  stress  its 
supreme  importance,  but  I should  like  to  offer  my 
opinion  that,  in  our  present  state  of  ignorance  of 
the  basic  cause  of  cancer,  intense  research  into  all 
and  every  method  which  may  facilitate  early 
recognition  of  the  disease  transcends  every  other 
type  of  cancer  research  and  is  paying  huge  divi- 
dends in  saving  life  and  alleviating  suffering. 

* Presented  at  the  George  Washington  University  Medical 
Society  Luncheon,  October  3,  1951,  during  the  Twenty-second 
.Annual  Scientific  Assembly  of  the  Medical  Society  of  the 
District  of  Columbia. 


GEOFFREY  HADFIELD,  M.D.,  E.R.C.P. 

Professor  of  Pathology,  Royal  College  of  Surgeons,  London 

There  is  a tendency  at  present  to  decry  the  ex- 
perimental approach  to  the  cancer  problem 
chiefly  because  the  two  types  of  research  have 
been  moving  along  parallel  lines  and  failing  to 
meet.  1 should  like  to  stress  this  point  strongly 
because  1 believe  we  must  check  it.  This  state  of 
affairs  is  partly  due  to  the  fact  that  the  labora- 
tory worker,  using  the  e.xperimental  animal  as  his 
test-object,  has  developed  the  habit  of  publishing 
his  results  in  highly  technical  language  which  his 
clinical  colleague  finds  difficult  to  understand.  Lie 
is  also  unwilling  to  leave  his  ivory  tower  and 
explain  his  methods,  aims  and  objectives  to  com- 
mon men. 

The  remedy  for  this  is  to  establish  closer 
liaison  between  the  two  classes  of  workers.  They 
must  work  in  close  proximity  with  each  other, 
and  the  liaison  officer  who  brings  them  together 
must  be  a man  who  has  great  sympathy  and  con- 
siderable understanding  of  both  aspects  of  the 
problem.  Before  coming  to  Washington  1 spent 
some  time  at  the  Memorial  Center,  New  York, 
and  I believe  that  Dr.  Rhoads,  the  Director  of 
that  Center,  has  achieved  this  difficult  task  and 
to  the  best  of  my  knowledge  is  the  only  man  in 
the  world  who  has  so  succeeded. 

There  is  another  reason  why  the  physician  and 
surgeon  is  sometimes  imjiatient  of  the  methods 
of  the  experimentalists.  Many  sane  and  well 


61 


62 


Cancer  Problem — Iladfield 


FEBRUARY,  1952 


balanced  clinicians  have  a deep  conviction  that 
what  happens  in  mice  does  not  of  necessity 
happen  in  man,  and  there  is  more  than  a grain 
of  truth  in  this  instinctive  belief. 

Let  me  remind  you  of  the  great  discovery  of 
Kennaway,  the  English  cancer  research  worker, 
who  isolated  a series  of  chemical  substances  from 
the  high  temperature  distillate  of  coal  tar  capable 
of  producing  malignant  growths  in  small  mam- 
mals in  every  tissue  of  their  bodies  and  in  very 
small  doses.  In  the  rhesus  monkey,  on  the  other 
hand,  those  compounds  are  almost  impotent,  and 
in  man  tar  cancer  is  slow-growing  and  readily 
amenable  to  treatment.  This  does  not  mean  that 
a mouse  cancer  differs  in  any  fundamental  way 
from  human  cancer.  There  is  no  doubt  whatever 
that  they  are  biologically  identical.  The  differ- 
ence lies  in  the  responsiveness  of  mouse  tissue  and 
the  failure  of  monkey  tissue  to  respond  to  a 
particular  cancer-producing  agent. 

I should  now  like  to  give  you  a general  impres- 
sion of  the  lines  along  which  the  more  promising 
experimental  work  is  progressing.  We  are  almost 
completely  ignorant  of  the  basic  reason  why 
certain  cells  in  the  body  assume  malignancy,  and 
in  this  sense  we  do  not  know  the  cause  of  cancer. 
Does  this  constitute  a valid  reason  why  we 
should  not  attempt  to  kill  cancer  cells  if  we  can 
find  a lethal  agent  to  which  they  are  susceptible 
while  the  rest  of  the  body  cells  are  immune?  The 
malarial  parasite  is  a living  cell,  but  malaria  was 
treated  successfully  by  quinine  long  before  the 
parasite  was  discovered. 

I believe  this  line  of  attack  to  be  the  most 
jiromising  under  investigation.  Let  me  give  you 
an  example.  Acute  encephalitis  is  often  due  to 
infection  by  a filter-passing  virus,  of  which  there 
are  quite  a large  number  of  varieties.  Many  of 
these  have  been  studied,  and  one  group  of  them 


has  been  found  which  produce  very  mild  and 
transient  effects  in  small  mammals  but  are  highly 
lethal  to  the  cells  of  an  engrafted  malignant 
tumor  in  these  animals. 

Is  it  unreasonable  to  hope  that  a virus  will 
eventually  be  found  which  will  enter  and  destroy 
human  cancer  cells,  leaving  the  normal  cells  of 
the  body  unharmed?  I believe  that  we  are  in 
sight  of  success  in  this  direction.  The  search  for 
agents  which  have  this  property  of  selective 
lethality  has  been  made  among  chemical  sub- 
stances which  normal  cells  need  for  normal 
growth  and  function.  The  substances  investi- 
gated have  been  certain  amino  acids  and  a group 
of  nucleic  acids.  Groups  of  atoms  are  substituted 
into  the  molecules  of  those  acids  without 
materially  altering  their  basic  structure.  They 
are  in  fact  so  little  altered  that  normal  cells  take 
them  up  out  of  the  blood  stream,  and  in  animals 
carrying  a malignant  growth  the  cancer  cells  do 
so  too.  Some  compounds  have  been  found  which 
are  harmless  to  normal  cells  but  by  virtue  of  the 
substituted  chemical  groupings  are  highly  lethal 
to  cancer  cells.  This  is  a vast  field  for  research, 
but  in  view  of  the  success  of  the  fundamental 
experiments  it  is  certainly  not  unreasonable  to 
hope  that  with  patience  and  determination  the 
ideal  selective  killing  agent  will  eventually  be 
found. 

In  giving  you  these  examples  I have  hardly 
scratched  the  surface  of  the  possibilities  of  experi- 
mental cancer  research  and  I believe  our  two 
countries  have  the  right  men,  and  these  men  have 
the  optimism  and  determination  to  pursue  this 
laborious  problem  to  the  bitter  end.  I need  not 
remind  you  that  this  would  not  be  the  first  time 
our  two  nations  have  brought  a long  struggle  to  a 
successful  ending. 


SYMPATHOMIMETIC  AMINES  IN  THE  TREATMENT 
OE  PERIPHERAL  CIRCULATORY  FAILURE* 


7 

^EW 


A.  M.  LANDS,  Ph.D. 

M.  L.  TAINTER,  M.D.,  Director 

Sterling-Wint/irop  Research  Institute,  Rensselaer,  N.  F. 


PROBLEMS  in  medical  research 
have  received  more  attention  than  those  associ- 
ated with  the  shock  syndrome.  The  sudden  and 
often  dramatic  appearance  of  this  phenomenon 
with  frequently  fatal  consequences  has  presented 
emergencies  requiring  prompt  remedial  treat- 
ment. The  selection  of  adequate  therapeutic 
measures  requires  reasonably  accurate  knowledge 
of  the  physiologic  condition  of  the  patient  and 
particularly  of  the  kind  and  extent  of  cardio- 
vascular changes  that  are  taking  place.  Blalock* 
has  divided  shock  or  peripheral  vascular  failure 
into  2 main  groups,  neurogenic  or  primary  shock 
and  hematogenic  or  secondary  shock.  This  latter 
group  involves  many  complex  physiologic 
changes  and  will,  therefore,  be  considered  first. 

Extensive  burns,  trauma  incidental  to  surgery, 
or  accidents  or  hemorrhage  may  induce  a train  of 
events  which  if  not  interrupted  will  result  in 
irreversible  shock  and  death.  Blalock*  and  Page- 
have  listed  these  events  in  the  following  order: 

SHOCK  FROM  HEMORRHAGE 


Reduced  blood  volume 

i 

Reduced  venous  filling 
Decreased  cardiac  outimt 

i 

Hy])otension 

i 

Carotid  sinus  and  other  reflexes 

i 

Vasoconsriction  + symj)athetic 
overactivity 


Tissue  ischemia 

Humoral 


Cardiac  acceleration 


* Delivered  at  the  Twenty-second  .Annual  Scientific  As- 
sembly of  the  Medical  Society  of  the  District  of  Columbia, 
October  2,  1951. 


Prolonged  ischemia  brings  about  changes  which 
appear  to  be  irreversible. 

Let  us  consider  briefly  the  evidence  leading  to 
the  above  generalizations.  Painful  or  disagreeable 
sensations  initiate  peripheral  vasoconstriction. 
Freeman  et  aP  have  determined  the  effect  of  pain 
on  the  volume  flow  of  blood  through  the  hand 
under  carefully  controlled  conditions  (see  figures 
1,  2 and  3).  In  these  experiments  pain  was  pro- 


BLOOD 

FLOW 


I n 

A B C 


MINUTES 

Fig.  1.  EfTect  of  jiain,  jiroduced  by  inflation  of  a balloon 
in  the  ileum  on  volume  flow  of  blood  through  hand  maintained 
at  constant  tem[)erature  of  31.6°  C.  (from  Freeman,  Shaw  and 
Snyder’) . 

.\,  H and  C:  Insertion  and  manipulation  of  balloon. 

D:  Inflation  of  balloon. 

duced  by  the  inflation  of  a balloon  which  had 
been  introduced  through  an  ileostomy  opening. 
This  caused  a marked  reduction  in  blood  flow 
which  lasted  for  as  long  as  the  cramps  persisted. 
Similar  reductions  in  periitheral  flow  have  been 
observed  in  emotional  states,  such  as  fear,  em- 
barrassment, disgust,  anxiety  and  annoyance. 


63 


64 


Synipathomimeiic  Amines — Lands  and  Tainler 


FEBRUARY,  1952 


However,  in  shock  this  response  is  more  marked. 
Thus,  in  a 54-year-old  housewife  suffering  from 
intestinal  obstruction  due  to  carcinoma  of  the 
sigmoid,  under  conditions  in  which  the  flow 
should  have  been  between  4 and  18  c.c.,  Freeman 
found  a maximum  flow  through  the  hand  of  only 
0.8  c.c.  per  100  c.c.  hand  volume  per  minute,  and 


Fig.  2.  Normal  control;  effect  of  increasing  temperature 
of  hand  on  volume  flow  of  blood  in  hand  and  oxygen  saluta- 
tion of  arterial  and  venous  blood  (from  Freeman,  Shaw  and 
Snyder^). 


a negligible  hyperemia  was  obtained  after  apply- 
ing the  tournicpiet  test.  Although  blood  was 
transfused,  the  patient  died  5 hours  later.  Page 
and  Abelb  have  made  direct  observations  of  the 
vascular  bed  of  a section  of  exteriorized  gut  and 
its  mesentery  placed  in  a special  observation 
chamber.  They  also  observed  extensive  vasocon- 
striction after  burns,  hemorrhage,  or  the  appli- 
cation of  a tourniquet. 

Simultaneous  with  the  increase  in  peripheral 
resistance  induced  by  trauma  there  is  a reduction 
in  circulating  blood  volume  (Blalock  and  Brad- 
burn^;  Blalock  and  Levy®;  Erlanger,  Gessell,  Gas- 
ser and  EllioT;  Ebert,  Hagen  and  Borden®).  In  a 
recent  experimental  study  of  the  mechanism  of 
shock  in  peritonitis,  Ebert,  Hagen  and  Borden® 
observed  a decrease  in  arterial  pressure,  concen- 
tration of  the  blood,  low  plasma  volume,  and  a 
fall  in  cardiac  output  in  dogs.  These  changes  re- 


semble those  following  hemorrhage.  Similar  re-  ' 
suits  have  been  obtained  by  Remington  et  aP~“ 
in  a comparison  of  the  effects  of  visceral  trauma, 
leg  muscle  trauma  and  hemorrhage.  They  report 
a greater  increase  in  peripheral  resistance  follow- 
ing trauma  than  after  hemorrhage,  this  elevated 
resistance  persisting  until  the  terminal  decline 
in  pressure  begins.  Prolonged  vasoconstriction 
brings  aliout  marked  changes  in  some  organs, 
particularly  the  intestine  and  liver,  these  changes 
apparently  resulting  from  an  inadequate  oxygen  ; 
supply  (Freeman,  Shaffer,  Schecter  and  Hol- 
ling'-;  Fine,  Seligman  and  Frank'®).  Such  changes 
can  be  delayed  or  prevented  in  experimental  ani- 
mals by  perfusion  of  the  splanchnic  area  or  by  , 
the  administration  of  agents  which  block  the 
sympathetic  nerves  (Remington,  Wheeler,  Boyd 
and  Caddell'L  Wiggers,  Ingraham,  Roemhild  and 
Goldberg'®;  Fine,  Seligman  and  Frank'®). 


BLOOD 

FLOW 

32r 

24 

16 

8 ■ 


2 0 ”C.  3 0 


^2 

SA  T. 


4 0 


100 

75 

50 

25 

0 


Fig.  3.  Surgical  shock  from  peritonitis;  effect  of  increasing 
temperature  of  hand  on  volume  flow  of  blood  in  hand,  and 
oxygen  saturation  of  arterial  and  venous  blood  (from  Freeman, 
Shaw  and  Snyder^). 


i 

< 


i 

! 

1 

1 

r 


I 

The  previously  outlined  sequence  of  events  ' 
seems  to  be  well  established  for  classical  shock.  ] 


But  we  may  ask,  how  often  is  this  exact  situation  ■ 
met  with  in  clinical  practice?  Usually  the  pa- 
tient in  shock  is  treated  under  conditions  in 


which  isotonic  fluids,  plasma  or  whole  blood  may  ' 
be  administered  to  replace,  at  least  in  part,  anv 

*■  I 


VOL.  XXI,  NO.  2 


Medical  Annals  of  the  District  of  Columbia 


65 


actual  reduction  in  circulating  volume.  This  may 
be  illustrated  by  a case  from  the  Institute  files.  A 
man  20  years  of  age  underwent  a laparotomy 
because  of  ileocecal  ulceration  with  fistula  forma- 
tion. An  ileotransverse  colostomy  with  resection 
of  the  ileum  was  done.  The  patient  went  into 
shock  postoperatively,  with  the  skin  cold  and 
clammy,  the  pulse  120  and  the  blood  pressure 
82  '60.  He  had  received  1,000  c.c.  of  blood  and 
1,300  c.c.  of  glucose  and  water  during  the  opera- 
tion. An  additional  500  c.c.  of  blood  failed  to  bring 
the  patient  out  of  shock.  At  this  juncture 
1-norepinephrine  (Levophed)  was  administered 
(8  mg.  in  1,000  c.c.)  with  a prompt  rise  of  the 
blood  pressure.  When  Levophed  was  discontinued 
for  a period  of  10  minutes  and  500  c.c.  of  blood 
started,  the  blood  pressure  fell  again  to  shock 
levels.  Levophed  was  able  to  maintain  the  blood 
pressure  at  proper  levels  with  disappearance  of 
all  signs  of  shock.  About  8 hours  later  the  blood 
pressure  dropped  to  shock  levels  (74/38)  in  spite 
of  the  administration  of  500  c.c.  of  blood.  Levo- 
phed was  started  again  and  maintained  the  pa- 
tient in  a normal  peripheral  vascular  state. 

Similar  results  have  been  reported  for  a series 
of  21  patients  varying  in  age  from  20  to  73  years 
and  representing  a cross-section  of  surgical  prac- 
tice. It  is  obvious  that  in  these  patients  there  are 
some  important  differences  from  those  reported 
for  classical  shock.  Inasmuch  as  a reduction  in 
circulating  blood  volume  is  apparently  not  an  im- 
portant factor  here,  may  there  not  be  some  pre- 
liminary reduction  in  vascular  tone  which  may 
precede  the  “irreversible”  changes  previously  re- 
ferred to  in  fatal  shock?  Lee  and  Zweifach'®  have 
described  an  initial  hyperreactive  phase  with  an 
intermediate  or  transition  period  in  hemorrhagic 
shock.  In  this  transition  period  vascular  re- 
activity becomes  less  pronounced  and  the 
additional  support  provided  by  a general  vaso- 
constrictor drug  such  as  Levoi)hed  or  Neo-Syn- 
ephrine  may  be  most  important.  The  effective- 
ness of  a general  vasoconstrictor  agent  may  be 
illustrated  by  results  obtained  by  Lord  ami  Hin- 
ton'^ and  Phillips  and  Nicholson,'**  who  have  used 
both  Levophed  and  Neo-Synephrine  with  com- 


parable results.  It  should  be  noted  that  infusion 
of  the  vasoconstrictor  provides  a more  uniform 
and  controllable  rise  in  blood  pressure  than  that 
from  intramuscular  injection  (see  figures  4 
and  5). 

We  have  previously  described  the  vasocon- 
striction and  cardiac  acceleration  which  indicate 
an  elevated  activity  of  the  sympathetic  nervous 
system.  This  has  been  shown  to  involve  the 
secretion  of  epinephrine  (Rapport'^).  Driessens^® 
studied  the  effect  of  trauma  in  the  curarized  dog 


Fig.  4.  Effect  of  Neo-Synephrine  intravenous  infusion  on 
maintenance  of  blood  jiressure  during  a thoracolumbar  sym- 
pathectomy (from  Lord  and  Hinton‘S). 


and  observed  an  epinephrine-like  hypertension 
associated  with  hyperglycemia  and  a reduction 
in  splenic  volume.  This  could  be  prevented  by 
ligation  of  the  adrenal  vein  and  diminished  by 
anesthetization  of  the  splanchnic  nerve  with  co- 
caine. The  secretion  of  epinephrine  is  considered 
an  adaptive  response  to  reinforce  sympathetic 
stimulation  in  emergency  states. 

The  pattern  of  actions  of  Levophed  and  Neo- 
Synephrine  in  man  differs  in  several  important 
characteristics  from  that  of  ejiinephrine,  and 
these  differences  may  offer  an  explanation  for  the 


66 


Sympathomimelic  Amines — Lands  and  Tainter 


FEBRUARY,  1952 


favorable  therapeutic  effects  previously  reported. 
Epinephrine  causes  marked  constriction  of  the 
cutaneous  and  splanchnic  vascular  beds  simul- 
taneously with  vasodilatation  of  the  blood  vessels 
of  the  skeletal  muscle.  These  changes,  along  with 
an  increased  pulse  rate,  are  well  suited  to  adjust 
the  organism  to  emergency  states  involving  flight 
or  combat  (the  emergency  pattern  of  Cannon-^. 
Levophed  and  Neo-Synephrine,  on  the  other 
hand,  cause  less  intense  vasoconstriction,  but 
they  cause  constriction  of  the  skeletal  muscle 


Ml  111 


Wc o r N« p h «>»>«  3 i.M. 

Fig.  5.  Effect  of  intramuscular  injections  of  Neo-Syn- 
ephrine on  maintenance  of  blood  pressure  during  thoraco- 
lumbar symiiathectomy  (from  Lord  and  Hinton'^). 

vessels  as  well  as  those  of  the  skin  and  splanchnic 
areas,  thus  producing  an  increase  in  total  pe- 
ripheral resistance  equal  to  or  greater  than  that 
obtained  with  a comparable  amount  of  epineph- 
rine. The  heart  is  slowed,  in  contrast  to  the  ac- 
celeration which  characterizes  the  action  of  epi- 
nephrine. Inasmuch  as  the  relatively  large  intra- 
muscular vascular  space  is  reduced,  more  blood 
is  shunted  into  the  other  portions  of  the  vascular 
system  where  a reduced  flow  may  cause  irre- 
versible changes. 

We  have  previously  cited  results  which  have 
shown  that  agents  preventing  or  reducing 


splanchnic  vasoconstriction  greatly  reduce  shock 
mortality.  The  e.xperimental  work  of  Cohn  and 
Parsons*-  and  Frank,  Seligman  and  Fine'-^  has 
shown  that  similar  results  are  obtained  by  pro- 
cedures which  maintain  an  adequate  flow  through 
the  liver  of  animals  e.xposed  to  trauma  or  hemor- 
rhage. Levophed  and  Neo-Synephrine  may  pro- 
vide well  such  an  increased  flow  at  the  expense  of 
the  vascular  bed  of  the  muscle.  This  may  be 
somewhat  analogous  to  the  results  obtained  by 
Glasser  and  Page,-^  who  demonstrated  the  effi- 
cacy of  intra-arterial  infusions,  which  may  pro- 
vide an  increase  in  flow  through  the  constricted 
splanchnic  blood  vessels  by  elevating  aortic  blood 
pressure. 

Neurogenic  or  primary  shock  results  from  a 
sudden  interruption  of  sympathetic  nervous  im- 
pulses to  the  peripheral  vascular  bed  so  that 
there  is  a rapid  reduction  in  vasomotor  tone  with 
a resultant  precipitous  fall  in  mean  arterial  pres- 
sure. There  is  no  important  change  in  circulating 
blood  volume.  This  form  of  shock  most  often 
results  from  factors  which  influence  the  nervous 
system  directly,  such  as  intracranial  injury,  deep 
anesthesia,  high  spinal  anesthesia,  sympathec- 
tomy, or  emotional  crises.  One  may  include  also 
the  action  of  peripheral  vasodilating  agents  such 
as  the  nitrites,  epinephrine  overdosage,  or  gan- 
glionic blocking  agents  which  may  induce  pe- 
ripheral vascular  collapse.  In  all  of  these  we  are 
dealing  primarily  with  a loss  of  vasomotor  tone 
which  may  be  readily  corrected  by  the  adminis- 
tration of  vasoconstrictor  drugs. 

This  may  be  illustrated  by  the  following  case 
histories.  A 20-year-old  soldier  suffered  a severe 
head  injury  after  falling  off  a truck.  He  became 
unconscious  a short  time  after  the  accident,  grew 
progressively  worse,  and  before  arriving  at  the 
hospital  spontaneous  respiration  had  ceased  and 
artificial  respiration  was  administered  by  means 
of  an  endotracheal  tube.  The  patient  was  mori- 
bund. He  was  operated  upon  immediately  and  a 
large  subdural  hematoma  removed.  However, 
after  operation  the  blood  pressure  remained  im- 
perceptible. Apparently  there  was  severe  hypo- 


VOL.  XXI,  NO.  2 


Medical  Annals  of  the  District  of  Columbia 


67 


tension  caused  by  central  depression.  Intra- 
venous Levophed  succeeded  in  raising  the  blood 
pressure  to  normal.  The  patient  was  kept  alive  in 
a respirator  for  2^  days  with  constant  intra- 
venous Levophed  or  Neo-Synephrine  adminis- 
tered by  infusion.  Although  the  patient  eventu- 
ally died,  this  case  demonstrates  the  effectiveness 
of  Levophed  and  Neo-Synephrine  in  maintaining 
blood  pressure  which  had  gone  to  subnormal 
levels  from  interference  with  the  vital  centers  of 
the  medulla. 

In  another  instance,  during  the  course  of  high 
spinal  anesthesia  the  patient  went  into  shock  and 
his  blood  pressure  fell  from  140/80  to  50/±. 
Levophed  infusion  was  started,  and  within  5 
minutes  the  blood  pressure  had  increased  to 
140  70.  The  anesthetic,  which  is  considered  to  be 
responsible  for  this  case  of  shock,  reached  the  6th 
cervical  vertebra.  Postoperatively  the  patient 
again  went  into  shock  and  lost  consciousness,  but 
consciousness  was  restored  and  the  blood  pres- 
sure was  elevated  with  the  use  of  intravenous 
Levophed  and  100  per  cent  o.xygen  by  bag  and 
mask  within  about  5 minutes. 

Sympathomimetic  amines  have  been  adminis- 
tered intramuscularly  to  maintain  blood  pressure 
after  spinal  anesthesia.  Lorhan  and  Lalich-®  have 
described  results  obtained  with  Neo-Synephrine 
in  150  cases  of  spinal  anesthesia  with  either 
pontocaine  or  novocain.  The  patients’  ages  varied 
from  17  to  79  years,  and  the  pressures  before  Neo- 
Synephrine  varied  from  60  to  190  mm.  Hg  sys- 
tolic and  40  to  130  mm.  Hg  diastolic.  The  intra- 
muscular administration  of  2. 5-5.0  mg.  of 
Neo-Synephrine  caused  an  elevation  of  pressure 
within  the  first  5 minutes  with  the  ma.ximum  rise 
at  15  minutes.  When  the  maximum  pressure  had 
been  attained  it  persisted  at  this  level  for  30  to  45 
minutes.  The  authors  report  further  that  the 
repetition  of  the  dose  was  found  to  be  effective  in 
all  cases. 

Ephedrine  is  an  effective  vasoconstrictor  for 
use  with  anesthesia  (Weinstein  and  Barron-®). 
However,  repeated  doses  lose  their  effectiveness, 
and  the  drug  may  stimulate  respiration  and  also 


cause  various  side-effects  resulting  from  central 
nervous  system  stimulation.  These  may  be  de- 
sirable in  shock  states  when  central  depression  is 
prominent.  Lorhan  and  Mosser”  have  obtained 
adecjuate  control  of  blood  pressure  with  propa- 
drine  in  a series  of  263  patients  anesthetized  with 
either  pontocaine  or  novocain.  The  optimal  dose 
of  50  mg.  given  intramuscularly  produced  a sus- 
tained elevation  of  blood  pressure  without  ap- 
parent harmful  side-effects.  Vasoxyl  has  been 
reported  to  be  effective  in  maintaining  blood 
pressure  during  spinal  anesthesia.  King  and 
Dripps,-®  using  doses  of  10  to  15  mg.  given  intra- 
muscularly just  prior  to  anesthesia,  observed  no 
important  reductions  in  pressure  in  the  majority 
of  a series  of  500  patients.  The  patients  in  the 
control  series  who  received  no  pressor  drug 
showed  an  average  fall  of  36  per  cent.  Similar 
results  have  been  obtained  by  Altschule  and  Gil- 
man-**  with  intramuscular  injections  of  10  to  20 
mg.  of  paredrine.  These  doses  will  cause  pressure 
elevations  lasting  from  \ to  more  than  2 hours. 
Thus,  the  elevation  of  blood  pressure  in  neuro- 
genic hypotension  is  easily  obtained,  and  there  is 
a wide  choice  of  sympathomimetic  agents  of 
established  efficacy. 

Vasoconstrictor  drugs  are  important  for  the 
maintenance  of  blood  pressure  in  sympathectomy 
operations.  Wilson  and  Bassett®”  have  described 
the  use  of  Levophed  in  112  patients  undergoing 
splanchnicectomy  and  lower  dorsal  sympathec- 
tomy. Operations  were  begun  5 to  10  minutes 
after  starting  the  infusion  of  Levophed  in  5 per 
cent  glucose,  the  rate  of  infusion  being  deter- 
mined by  the  blood  pressure  level.  Satisfactory 
pressures  were  maintained  during  operation  with- 
out transfusions  or  supplementary  vasopressor 
agents.  Similar  results  have  been  obtained  by 
Deterling  and  Apgar®'  during  36  stages  of 
thoracolumbar  sympathectomy  performed  in  an 
unselected  group  of  21  jiatients  (see  figures  6 
and  7). 

Numerous  recent  reports  have  described  par- 
oxysmal hypertension  resulting  from  excess  secre- 
tory activity  of  adrenal  medullary  tumors  or 


Sympathomimetic  Amines — Lands  and  Tainter 


FEBRUARY,  1952 


6S 

pheochromocylomala  ( reviewed,  Goldeiiberg^) . 
Surgical  removal  frec|uently  causes  a sudden  and 
profound  hypotension.  Pantridge  and  Burrows'*''’ 
have  described  the  successful  removal  of  a pheo- 
chromocytoma  in  a 66-year-old  woman.  During 
the  19  minutes  after  clamping  the  tumor  pedicle 
40  c.c.  of  a solution  containing  10  jug.  of  Levo- 
phed/c.c.  was  given  intravenously  with  resultant 
restoration  of  blood  pressure  to  safe  levels.  Sub- 


CS  cT  S5 

LEFT  THOBACOLUMeAR  SYMPATHECTOMY 
T-8.  L-2. 

SECOND  STAGE 
8-21-48 


ANESTHESIA  ETHEB-O, 

INDUCTION  IV  PENTOTHAL 
ENDOTRACHEAL  TUOE 
DURATION  8 HRS  . 18  MIN 
OPERATION  2 HRS  . 88  MiN 
MEDICATION  BLOOO  TOO  CC 
SALINE  800  CC 
NOREPI  82  HC 


Delerling  and  .\pgar^*). 


secpiently  the  pressure  was  maintained  by  a 
Levophed  drip  which  was  continued  for  40  hours. 
Palmer  (reported  by  Goetz'’’^)  has  observed  simi- 
lar results  following  the  removal  of  a jiheo- 
chromocytoma.  The  pressure  drojiped  to  70/40 
but  was  promptly  restored  to  normal  levels  by  a 
Levophed  drip,  this  being  used  to  sujiport  blood 
pressure  over  a 15-hour  postoperative  period.  In 
these  cases,  the  slow  infusion  of  a vasoconstrictor 
drug,  adjusted  to  the  patient’s  need,  has  served 
as  a “pharmacologic  crutch’’  until  homeostatic 
mechanisms  were  again  functioning  adecjuately. 


Summary 

In  neurogenic  or  primary  shock  there  is  a 
sudden  reduction  of  vasomotor  tone  which  is 
readily  restored  by  sympathomimetic  vasocon- 
strictor drugs.  There  is  a wide  choice  of  agents 
suitable  for  this  i)urpose.  However,  hematogenic 
or  secondary  shock  involves  a comple.x  series  of 


vascular  changes  wherein  sympathomimetic 
drugs  such  as  epinephrine  have  been  considered 
to  be  contraindicated.  In  such  cases  recent  clini- 
cal investigations  have  demonstrated  that  in- 
fusions of  Levophed  (1 -norepinephrine)  or  Neo- 
Synephrine  can  restore  the  blood  pressure  and 
possibly  the  blood  flow  to  normal  and  maintain 
it  usually  as  long  as  the  infusion  is  continued  or 
until  recovery  occurs.  The  very  informative  case 
reported  recently  by  Luger,  Kleiman  and  Fre- 
monP'’  illustrates  that  Levophed  can  maintain 
the  blood  pressure  for  days  if  necessary  until  the 
otherwise  fatal  vascular  atony  has  had  time  to  be 
alleviated.  It  is  suggested  that  this  beneficial 
action  results  from  a redistribution  of  blood 
whereby  an  increase  in  the  volume  flow  through 
the  splanchnic  bed  is  obtained,  thus  diminishing 
the  danger  of  irreversible  shock.  This  new-found 


HO  4 82 

MIGHT  THORACOLUMBAR  SYMPATHECTOMY 
T-t.  L-  2. 

SECOND  STAGE 


anesthesia  EThER-Oj 

MOUCTION  N2O 
DURATION  8 HRS  . 20  MIN 
OPERATION  2.  MRS,  to  MIN 
MEDICATION  BLOOD  800  CC 
SALINE  800  CC 
NEOSYN  18  MG 


Fig.  7.  ICffecls  of  single  doses  of  Neo-Synephrine  on  sys- 
temic blood  jiressure  following  sympathectomy  (from  Deterling 
and  .V])gar'”). 

ability  of  Levophed  to  maintain  the  blood  pres- 
sure in  spite  of  the  profound  shock  process  robs 
the  shock  state  of  much  of  its  danger  and  is 
certain  to  result  in  e.xtensive  saving  of  life. 

HIBLIOGRArilY 

1.  Blalock,  .\.:  Brincijiles  of  Surgical  Care,  Shock  and  Other 

Problems.  St.  Louis:  Mosby,  1940. 

2.  Page,  I.  H.:  Am.  Heart  J.,  1949,  38,  161. 

3.  Freeman,  N.  W.,  Shaw,  J.  L.,  and  Snyder,  J.  C.:  J.  Clin. 

Investigation,  1936,  15,  651. 

4.  Page,  I.  H.,  and  .\bell,  R.  G.:  .\m.  J.  Physiol.,  1945, 

143,  182. 

5.  Blalock,  A.,  and  Br.adburn,  H.:  Arch.  Surg.,  1930, 

20,  26. 

6.  Blalock,  and  Levy,  S.  FL;  .Vm.  J.  Physiol.,  1937, 

118,  734. 

(Couliiiued  on  page  122) 


THERMAL  INJURIES  IN  ATOMIC  WARFARE 


C ^ / N ATOMIC  bomb  explosion  of  the 
Hiroshima  type  is  accompanied  by  the  release  of 
enormous  quantities  of  kinetic  energy,  mostly  in 
the  form  of  ordinary  heat  commonly  recognized 
as  infrared,  visible  and  ultraviolet  radiation.  The 
remaining  portion  of  this  energy  is  released  as 
blast  and  nuclear  radiation.  Immediately  below 
the  bomb  burst  and  out  to  the  distance  of  about  2 
or  3 miles  structural  damage  to  buildings  is  very 
great.  Wooden  structures  are  flattened,  but  rein- 
forced concrete  seems  to  withstand  the  blast 
effect  quite  well.  One  of  the  important  secondary 
effects  of  blast  is  the  disruption  of  water  and  gas 
lines  and  the  starting  of  many  secondary  fires. 

The  nuclear  radiation  is  confined  to  a radius 
of  about  1 mile,  being  most  intense  immediately 
beneath  the  bomb  burst.  Radiation  hazard  in 
this  zone  is  very  real  and  is  due  to  gamma  and 
neutron  radiation.  The  penetrating  power  of  neu- 
tron radiation  is  so  great  that  only  very  thick 
concrete  or  earthen  structures  protect  life.  I be- 
long to  the  school  that  considers  the  conventional 
or  more  newly  designed  thick  concrete  bomb 
shelters  as  devices  ill  designed  to  protect  many 
of  a city’s  population  and  too  expensive  for  the 
protection  they  do  afford. 

In  this  discussion  I will  dwell  little  on  damage 
from  neutron  or  gamma  radiation  because  I per- 
sonally have  had  no  experience  with  it.  There  is 
no  very  effective  remedy  against  large  scale  ir- 
radiation, the  only  treatment  being  supportive, 
generally  of  the  same  type  that  is  used  in  the 
management  of  wounds  and  burns. 

'Fhe  third  type  of  injury,  burns,  is  important 
because  thermal  injury  constitutes  an  important 
cause  of  death  in  atomic  attack.  Thermal  injury 

* Delivered  al  the  Twenty-second  .\nnual  Scientific  .\s- 
semhly  of  the  .Medical  Society  of  the  District  of  Columhia, 
October  2.  1951. 


EVERETT  IDRIS  EVANS,  M.I). 

Professor  of  Surgery  and  Director  of  Surgical  Research  Labora- 
tories, Medical  College  of  Virginia,  Richmond 


is  extreme  immediately  beneath  the  bomb  burst. 
The  attentuation  of  the  thermal  flux  with 
distance  is  much  less  than  with  nuclear  radiation; 
moderate  to  severe  thermal  injury  can  occur  out 
to  approximately  3 miles.  In  the  inner  zone,  from 
the  hypocenter  to  about  1 mile,  the  heat  is  ex- 
ceedingly intense  and  no  living  thing  can  survive 
its  destructive  effect.  On  out  from  the  periphery 
of  the  1-mile  zone,  up  to  about  3 miles,  the  burn 
destruction  would  become  less  serious. 

Types  of  Thermal  Injury 

Thermal  injury  to  atomic  bomb  explosions  is 
of  2 types,  the  “flash  burn’’  and  the  secondary, 
deeper  burn.  The  flash  burn  is  almost  unique  to 
atomic  bomb  explosions  but  is  seen  not  too  in- 
frequently in  civilian  practice  because  of  ex- 
plosions of  gases  in  a closed  space.  The  flash  burn 
affects  only  the  exposed  surfaces  of  the  body, 
namely,  the  hands,  arms  and  face,  and  differs 
from  the  ordinary  burn  mainly  in  that  the 
damage  is  inflicted  in  an  exceedingly  short  rather 
than  a long  period  of  time.  At  the  3-mile  pe- 
riphery these  burns  would  be  very  superficial, 
resembling  sunburn,  but  as  one  approaches  the  1- 
mile  zone  the  burns  of  the  exposed  portions 
would  be  deeper.  These  flash  burns  may  be  of 
either  first  or  second  degree  and  from  the  Hiro- 
shima experience  are  (]uite  painful. 

It  is  my  conviction  that,  although  the  “flash 
burn’’  is  very  important  in  atomic  warfare,  in 
populations  housed  in  crowded  cities  such  as  in 
America  the  secondary  burn  would  be  encoun- 
tered more  often  and  would  be  more  serious. 
Secondary  burns  usually  occur  as  a result  of 
clothing  catching  fire  in  the  attempt  of  the  victim 
to  esca[)e  a burning  building.  As  Harvey  Allen' 
has  so  clearly  pointed  out,  these  secondary,  deep 


69 


70 


Thermal  Injuries  in  Atomic  Warfare — Evans 


FEBRUARY,  1952 


l)urns  are  not  confined  to  an  arm  or  leg  but 
usually  affect  several  portions  of  the  body  and  in 
many  instances  involve  the  whole  circumference 
of  one  or  more  limbs  and  or  the  trunk  or  thorax. 
In  other  words,  they  tend  to  be  extensive.  Be- 
cause the  heat  damage  is  inflicted  over  a longer 
period  of  time  these  burns  generally  are  deep. 

It  is  well  to  remember  that  in  atomic  warfare 
the  resulting  injury  may  be  very  complex.  Burns 
with  serious  associated  injury  should  be  expected. 
The  associated  injury  is  usually  related  to  the 
blast  effect  of  the  bomb  with  multiple  lacerations 
and  glass  wounds  from  flying  debris  and  frac- 
tures, simple  and  compound.  A burn  injury  is 
difflcult  enough  to  treat  by  itself;  when  it  is 
associated  with  complicating  injuries  such  as 
multiple  wounds  of  the  limbs,  abdomen  or  thorax, 
or  skeletal  trauma,  all  the  hazards  of  infection  and 
shock  are  greatly  multiplied.  Planning  for  proper 
medical  care  in  atomic  attack  involves  thinking 
along  military  surgery  lines.  The  simple  surgery 
of  jjeacetime  trauma  may  not  prove  sufficient  or 
effective. 

As  pointed  out  above,  the  extent  and  depth  of 
thermal  injury  following  an  atomic  bomb  ex- 
plosion depend  on  the  position  of  the  individual 
at  the  time  of  the  explosion.  In  the  1-mile  zone 
victims  with  thermal  injury  may  have  very 
serious  burns.  It  is  likely  they  will  also  have 
suffered  extreme  trauma  as  a result  of  blast  and 
very  serious  radiation  unless  they  happen  to 
have  been  protected  by  many  feet  of  concrete  or 
dirt.  In  the  1-  to  3-mile  zone  burns  would  be 
either  of  the  flash  type  involving  the  exposed 
surface  of  the  body  or  secondary  as  a result  of 
burning  buildings  or  clothing.  The  important 
details  of  Imrn  care  for  these  victims  comprise: 

1.  An  estimate  of  the  extent  of  thermal  injury. 

2.  An  estimate  of  the  severity  of  complicating 
injury. 

3.  Proper  identification  of  the  victim’s  position 
at  the  time  of  e.xplosion. 

4.  Relief  of  pain. 

5.  The  management  of  burn  shock. 

6.  Fluid  and  electrolyte  care. 

7.  Care  of  the  burn  wound. 


Extent  of  Burns 

The  extent  of  thermal  injury  should  be  esti- 
mated as  soon  as  possible,  because  it  relates  to 
effective  management  of  shock  and  proper  dispo- 
sition and  later  care  of  the  burn  victim.  If  the 
burned  area  is  above  20  per  cent  of  the  body 
surface  the  patient  will  probably  go  into  moder- 
ate or  severe  shock  unless  antishock  measures 
are  employed.  The  more  the  delay,  the  more 
difficult  it  will  be  to  treat  shock  with  ultimate 
success. 

One  of  the  disheartening  features  of  effective 
medical  management  after  atomic  attack  may  be 
the  disposition  of  those  so  hopelessly  burned  or 
otherwise  injured  that  no  medical  care  can  ac- 
complish survival.  There  is  no  truly  effective 
peacetime  treatment  for  burns  of  about  50  to  60 
per  cent  of  the  body  surface,  even  by  those  in 
well  conducted  surgical  clinics  highly  experi- 
enced in  burn  therapy.  In  atomic  warfare  with 
patients  with  burns  of  that  extent  the  chief  re- 
s])onsibility  of  the  physician  will  be  to  relieve 
pain  and  suffering  and  then  turn  his  attention  to 
the  effective  care  of  the  less  seriously  injured. 

Complicating  F.actors  in  Severe  Burns 

Since  respiratory  tract  burns  constitute  one  of 
the  most  serious  complicating  features  of  thermal 
injury,  the  physician  must  learn  at  once  whether 
the  jiatient  with  a burn  has  a complicating  re- 
spiratory tract  .burn.  Rapid  but  careful  exami- 
nation of  the  nose  and  throat  and  noting  wffiether 
the  victim  has  hoarseness,  speaks  in  a husky 
voice,  or  has  rather  severe  coughing  attacks  will 
establish  this.  The  complication  of  respiratory 
tract  injury  greatly  increases  the  mortality  of 
burns  even  in  peacetime. 

The  physician  or  first-aid  worker  must  ascer- 
tain by  observation  and  examination  the  pres- 
ence of  a serious  complicating  injury  in  a burn 
victim.  Although  the  burn  may  be  fairly  exten- 
sive (around  25  to  30  per  cent),  if  the  victim  also 
has  a fracture  of  one  of  the  major  portions  of  the 
lower  limbs  or  pelvis,  the  ensuing  shock  from 
whole  blood  loss  may  be  more  important  than 


VOL.  XXI,  NO.  2 


Medical  Annals  of  the  District  of  Columbia 


71 


the  immediate  care  of  the  burn  wound.  .\lso,  if 
there  is  a complicating  penetrating  injury  of  the 
abdomen  or  thora.x  in  an  e.xtensive  burn,  the 
complicating  injury  has  precedence  in  therapy. 
It  may  require  early  surgical  operation  to  stop 
serious  bleeding  or  to  ward  off  inevitable  infection 
in  the  case  of  a perforated  viscus  from  an  ab- 
dominal wound. 

Proper  Identification 

This  is  the  problem  for  the  first-aid  worker  and 
is  of  interest  only  for  those  living  victims  in  the 
zone  from  the  hypocenter  out  to  about  1 \ miles. 
The  first-aid  worker  should  note  on  the  identifi- 
cation tag  the  position  of  the  victim;  even  though 
he  is  found  at  the  periphery  of  the  1^-mile  zone 
he  will  still  have  received  enough  external  body 
radiation  to  effect  eventual  outcome.  Studies- 
under  way  in  our  laboratory  indicate  the  im- 
portance of  the  complicating  feature  of  even 
small  amounts  of  external  radiation  when  com- 
bined with  thermal  injury. 

Relief  of  Pain 

Pain  may  be  an  important  factor  in  those 
patients  with  superficial  burns,  but  it  is  well  for 
the  physician  or  first-aid  worker  to  realize  that 
this  pain  is  best  relieved  by  proper  cover  of  the 
wound  and  not  by  large  doses  of  opiates.  Pain 
from  burn  wounds  is  readily  relieved  by  cover  of 
the  burn  wound  with  a simple  dressing  to  exclude 
air.  If  shock  is  present  opiates  should  be  given  in 
small  amounts  only  (morphine,  0.015  Gm.  or  I 
grain,  or  codeine,  0.065  Gm.  or  1 grain).  The 
important  observations  of  Beecher*  on  the  pain- 
relieving  properties  of  certain  of  the  barbiturates 
should  be  remembered.  Much  of  what  passes  for 
pain  is,  in  reality,  the  manifestation  of  hysteria, 
and  hysteria  is  not  well  treated  by  opiates.  The 
shorter-acting  barbiturates  are  much  more  effec- 
tive and  safer. 

'Freatment  of  Burn  Shock 

If  the  extent  of  the  burn  is  less  than  20  jier 
cent  of  the  body  surface  and  the  oral  salt  and 


bicarbonate  solutions  advocated  by  Moyer^  can 
be  taken  in  adecpiate  amounts,  shock  should  be 
no  problem.  These  solutions  should  be  given  and 
retained  in  amounts  large  enough  to  maintain  a 
steady  output  of  urine.  If  the  extent  of  the  burn 
is  20  to  35  per  cent  of  the  body  surface,  1 to  2 
liters  of  plasma  or  plasma  substitutes  must  be 
given  intravenously  in  the  first  24  hours  with 
about  one  half  of  this  amount  the  second  day. 
Burns  greater  than  35  per  cent  recjuire  whole 
blood  in  equal  quantities  with  plasma  or  plasma 
substitutes  in  order  that  shock  may  be  pre- 
vented. As  stated  above,  burns  involving  more 
than  50  [ler  cent  of  the  body  require  so  much 
blood  and  so  much  skilled  medical  and  nursing 
attention  that  it  is  quite  impossible  to  envisage 
this  abundance  of  care  after  atomic  attack. 

Fluid  and  Electrolyte  Therapy 

The  most  critical  period  for  proper  fluid  and 
electrolyte  replacement  in  the  burn  patient  is  the 
first  48  hours.  Oral  salt  and  water  therapy  is 
sutificient,  if  taken  in  adequate  amounts,  in  those 
burns  of  less  than  20  per  cent.  For  more  exten- 
sive burns  I believe  it  will  be  imperative  to 
arrange  for  intravenous  therapy  of  salt  and 
water.  Generally  the  burn  victim  requires  about 
the  same  amount  of  salt  solution  as  plasma 
and  or  whole  blood  during  the  first  2 days.  Addi- 
tional water  is  given  to  insure  a urine  output  of 
from  25  to  50  c.c.  per  hour  in  adults.  This  means 
that  an  adult  burn  victim  should  excrete  approxi- 
mately 1 liter  of  urine  the  first  day.  After  atomic 
attack  the  adecpiacy  of  shock  and  of  fluid  and 
salt  therapy  might  be  simply  measured  by  the 
burn  victim  passing  enough  urine  in  the  first  24 
hours  to  fill  a (piart  bottle. 

It  is  highly  imiiortant  with  burn  victims  with 
res{)iratory  tract  damage  to  give  fluid  therapy 
only  in  amounts  sufficient  to  insure  a satisfactory 
urine  output,  inasmuch  as  they  are  very  sus- 
ceptible to  early  or  late  pulmonary  edema.  I 
emphasize  that  whole  blood  must  be  given  for 
shock  in  those  victims  who  have  serious  associ- 
ated injuries,  ('are  must  l)e  taken  that  not  too 


72 


Thermal  Injuries  in  Atomic  Warfare — Evans 


FEBRUARY,  1952 


large  amounts  of  plasma  or  plasma  substitutes 
are  administered  in  the  early  phase  of  treatment. 

Treatment  of  Burns 

Burn  wound  care  falls  into  2 simple  categories, 
(1)  the  closed,  and  (2)  the  open-e.xposure  treat- 
ment. These  2 methods  are  not  mutually  ex- 
clusive, and  in  the  same  victim  the  intelligent 
physician  may  hnd  himself  using  both  methods 
on  different  parts  of  the  body. 

With  the  closed  method  every  attempt  is  made 
to  cover  the  burn  wound  with  a satisfactory 
dressing  that  prevents  seeding  of  the  burn  wound 
by  microorganisms  falling  on  the  wound  or 
brought  to  the  wound  by  unclean  hands  or  dirty 
instruments.  The  method  now  utilizes  various 
tyiies  of  sterile  dressings,  either  with  dry  inner 
surfaces  or  a gauze  coated  with  petrolatum  or 
other  suitable  ointments.  Recently  Harvey  Allen^ 
and  our  group  have  developed  a simple  one- 
piece  dry  dressing  which  can  be  cjuickly  and 
easily  applied  by  relatively  untrained  persons  to 
even  an  extensive  burn  wound.  This  dressing, 
procurable  in  2 sizes,  22  x 18  and  22  x 36  inches, 
has  recently  been  approved  by  the  Subcommittee 
on  Burns  of  the  National  Research  Council  for 
use  by  the  Civil  Defense  and  military  authorities, 
and  stockpiling  of  it  for  atomic  disaster  use  is  now 
under  way.  This  dressing  greatly  simplifies  the 
closed  method  of  burn  wounds,  and  there  is  every 
reason  to  believe  that  in  atomic  warfare  it  will 
be  very  useful.  This  dressing  will  likely  be  highly 
useful  for  the  emergency  covering  of  other  types 
of  serious  wounds  resulting  from  the  bomb.  There 
is  more  or  less  general  agreement  that  the  closed 
method  of  burn  care  is  best  for  circumferential 
burns,  such  as  around  a leg  or  trunk  and  for 
burn  victims  requiring  transfer  to  a hospital  for 
more  definitive  care. 

The  term  “open  or  exposure”  treatment  of 
burns  implies  exactly  that  leaving  the  burn 
wound  uncovered  and  allowing  it  to  dry  under 
the  proper  conditions.  This  method  is  under 
serious  study  in  several  active  burn  clinics  in 
this  country  and  abroad.  Some  surgeons  believe 


that  in  the  chaos  that  may  follow  atomic  attack, 
this  method  would  have  to  be  used.  The  open 
method  seems  to  work  very  well  with  superficial 
burns.  It  has  been  given  a less  severe  test  with 
the  deep,  full  thickness  burn,  but  under  certain 
precautions  where  rapid  drying  results  the  open 
air  method  seems  to  work  quite  well  with  them. 
It  is  much  less  effective  than  the  closed  method  in 
extensive  circumferential  burns  involving  the 
limbs  and  trunk,  because  with  the  open  method 
rapid  drying  of  the  burn  wound  is  less  easily 
accomplished. 

Both  methods  require  moderately  expert  surgi- 
cal and  nursing  care,  and  neither  method  is  suc- 
cessful if  neglect  is  allowed.  The  successful  use  of 
either  method  requires  more  or  less  constant 
attention  of  the  physician  and  nurses  so  that 
burn  patients  receive  enough  fluids  and  salt  to 
ensure  an  adequate  urine  output,  proper  food  in 
amounts  great  enough  to  ward  off  malnutrition, 
adequate  antibiotic  therapy  to  ward  off'  infection, 
and  surgical  therapy  at  the  proper  time  to  cover 
those  portions  of  the  body  in  which  the  burn  has 
been  so  deep  that  full  skin  thickness  loss  occurs. 

Preparation  for  Atomic  Attack 

The  important  groiqis  of  personnel  necessary 
for  this  work  will  be  (1)  rescue  workers,  (2) 
first-aid  workers,  and  (3)  medical  and  nursing 
personnel.  It  is  not  in  my  province  to  discuss  the 
hazards  of  radiation  for  those  rescue  workers 
who  must  go  into  the  zone  of  greatest  damage  to 
bring  out  victims  after  bombing  attack.  I am  in 
agreement  with  Brigadier  General  James  Cooney 
in  the  belief  that  in  a democracy  these  hazards, 
although  considered  by  some  to  be  great,  must 
be  considered  insignificant  when  human  lives  are 
concerned.  To  be  effective,  the  rescue  workers 
must  go  into  these  areas  to  aid  any  surviving 
victims  as  soon  as  possible  after  the  attack.  Of 
course,  they  should  be  accompanied  or  preceded 
by  radiation  monitors,  but  we  must  develop  a 
more  realistic  view  of  what  truly  constitutes 
radiation  hazard  in  times  of  such  emergency. 
After  all,  the  rescue  workers  may  not  spend  very 


VOL.  XXI,  NO.  2 


Medical  Annals  of  the  District  of  Columbia 


73 


much  time  in  that  zone.  Also,  we  must  never  for- 
get that  should  atomic  attack  ever  be  made  on 

o 

our  cities  or  soldiers,  we  will  be  fighting  for  our 
very  survival  as  a nation  of  free  people. 

Rescue  squads  similar  to  those  trained  in  Eng- 
land during  the  past  war  will  be  needed  in  large 
numbers  to  bring  out  victims  from  demolished 
and  burning  buildings.  I am  happy  to  note  these 
workers  are  under  training  at  this  time  in  several 
of  our  larger  cities,  including  Washington. 

The  first-aid  worker  will  be  needed  in  very 
large  numbers  to  help  in  the  care  of  burn  victims. 
It  is  surprising  how  much  useful  medical  informa- 
tion can  be  taught  to  intelligent  lay  personnel. 
These  and  nurses  must  be  available  at  first-aid 
stations  and  hospitals  to  handle  the  bulk  of  care 
for  atomic  attack  victims. 

Medical  personnel  may  be  so  scarce  in  an 
affected  city  that  it  will  be  necessary  to  bring  in 
from  adjoining  towns  or  nearby  cities  additional 
personnel.  In  all  events,  such  personnel  will  be  so 
scarce  as  to  require  severe  rationing  of  their 
services.  There  is  a serious  deficiency  in  surgeons 
trained  in  the  school  of  emergency  surgery;  only 
war  and  battle  train  such  surgeons. 

Not  the  least  in  importance  are  the  large 
numbers  required  for  proper  fire  fighting  and 
transportation  of  the  wounded. 

National  Blood  Program 

I have  recently  been  quoted  as  intimating  there 
is  no  longer  any  need  for  whole  blood  or  plasma 
now  that  we  have  effective  plasma  substitutes 
available.  Permit  me  to  make  my  position  so 
clear  that  there  can  be  no  misunderstanding 
about  my  views. 

1 have  for  the  i)ast  10  years  been  studying  the 
problem  of  the  best  treatment  for  traumatic  and 
burn  shock.  If  I have  learned  anything  it  is  that 
most  cases  of  shock  from  trauma  are  best  treated 
by  the  use  of  whole  blood.  In  e.xtensive  burns 
whole  blood  again  is  the  treatment  of  choice. 
Plasma  substitutes  such  as  gelatin  or  de.xtran 
appear  to  be  highly  effective  in  burn  shock  of 


lesser  degrees,  but  they  cannot  and  never  will 
take  the  place  of  whole  blood 

I wrote  as  late  as  April  28,  1951  in  the  Journal 
of  the  American  Medical  Association,  “Because 
one  of  the  first  and  most  urgent  needs  of  the 
trauma  patient  is  for  whole  blood  or  plasma, 
Americans  must  organize  at  once  a system  on  a 
national  scale  that  will  make  readily  available 
large  supplies  of  whole  blood  and  plasma.”^  I had 
stated  earlier  in  the  same  journal,  “No  informed 
person  who  has  clearly  and  justly  considered  the 
magnitude  of  the  problem  of  adequate  medical 
'care  that  would  follow  an  atomic  attack  on 
American  cities  can  fail  to  recognize  the  neces- 
sity for  a truly  national  blood  program.”® 

Those  statements,  made  in  absolute  sincerity, 
should  make  my  position  clear.  My  present  stand 
is  exactly  as  stated,  but  I would  add  this:  If  as  a 
nation  of  informed  and  brave  free  men  we  do  not 
at  once  make  effective  a national  blood  program 
in  association  with  the  American  Red  Cross  and 
hospital  and  private  blood  banks,  we  face  disaster 
if  atomic  attacks  should  come. 

It  is  obvious  that  the  national  blood  program 
at  this  time  is  not  truly  effective.  How  do  we 
know  that  such  is  the  case?  Every  day  in  every 
leading  newspaper  there  is  to  be  noted  a plea 
from  lay  persons  and  the  Church  for  more  blood 
donors  in  order  that  vitally  necessary  supplies  of 
whole  blood  and  plasma  can  be  delivered  to  our 
wounded  in  Korea.  The  response  has  been  so  poor 
that  recently  the  military  authorities  have  been 
forced  to  add  their  apjieal  in  newspapers  and 
over  radio  and  television  for  this  blood.  The  cry 
is  made  daily  for  “Blood,  Blood,  Blood,”  and  still 
there  is  not  sufficient  blood. 

Wherein  lies  the  fault?  Understandably  there 
have  been  mistakes  on  the  ])art  of  all  of  us  who 
have  been  engaged  in  the  national  blood  program. 
.\  discussion  of  these  errors  is  of  little  avail.  The 
fundamental  and  glaring  fault  rests  with  each 
citizen.  \'ou  and  1 simi)ly  have  not  given  our 
blood.  How  in  the  name  of  all  conscience  and 
human  clecency  can  we  fail  to  respond  to  this 


74 


I'hermal  Injuries  in  Atomic  Warfare — Evans 


FEBRUARY,  1952 


urgent  call?  The  answer  is  simple.  It  is  a failure 
of  the  American  people. 

There  is  not  time  for  me  to  discuss  the  ex- 
tremely important  problem  of  adequate  medical 
supplies  for  the  care  of  atomic  burn  victims.  You 
are  all  aware  that  only  recently  the  Congress  has 
turned  down  the  requests  of  the  Civil  Defense 
authorities  for  the  amounts  of  money  needed  to 
acquire  these  supplies.  Again  I would  remind  you 
that  we  should  be  slow  to  place  all  the  blame  for 
this  action  on  Congress.  How  can  we  expect 
Congress  to  be  truly  aware  of  these  needs  when  we 
note  the  apathy  of  the  citizens  in  their  response 
to  the  call  for  blood?  I am  convinced  that  if  in  the 
next  months  the  citizenry  showed  their  faith  in 
the  requests  of  the  Civil  Defense  authorities  for 
these  supplies  by  responding  to  the  call  for  blood, 
this  would  help  greatly  to  alert  Congress  to  the 
needs  of  the  hour. 

In  closing,  let  me  state  once  more  that  we 
invite  disaster  and  defeat,  not  by  Russia’s 
strength  but  by  our  own  negligence.  Across  the 
strife-torn  centuries  I can  hear  the  voice  of 


Demosthenes  crying  to  his  beloved  Athenia, 
“Everyman,  where  he  can  and  ought  should  give 
his  service  to  the  state  without  excuse;  in  a 
word,  plainly,  if  each  of  you  will  become  your 
own  master  and  cease  to  do  nothing,  while  your 
neighbor  does  everything  for  you,  you  shall  then 
with  heaven’s  permission  recover  your  own,  and 
get  back  what  has  been  frittered  away.  For  your 
enemy  has  been  exalted  not  so  much  by  his  own 
strength  as  by  your  negligence.’’ 

BIBLIOGRAPHY 

1.  Allen,  H.  : Personal  communication. 

2.  Brooks,  J.,  and  Evans,  E.  I.;  Influence  of  combined  ex- 

ternal body  radiation  and  standard  thermal  injury  in 
dog,  in  preparation. 

3.  Beecher,  H.  K.:  Delayed  morphine  poisoning  in  battle 

casualties.  J.A.M.A.,  1944,  124,  1193. 

4.  Moyer,  C.  A.:  Fluid  and  electrolyte  therapy  in  burns, 

from  Symposium  on  Burns,  National  Research  Council, 
Washington,  D.  C.,  Nov.  2-4,  1950,  page  47. 

5.  Evans,  E.  I.:  .\tomic  burn  injury.  J.,\.M..\.,  1951,  145, 

1342. 

6.  Evans,  E.  L:  Burn  problem  in  atomic  warfare.  Ibid., 

1950,  143,  1143. 


CLINICAL  EVALUATION  OF  VERGITRYL,  A NEW, 
HIGHLY  PURIFIED  EXTRACT  OF 
VERATRUM  VIRIDEn 


HE  AVAILABILITY  of  a highly  puri- 
fied, well  standardized  preparation  of 
Veratrum  viride  (VergitrylJ)^  in  both  parenteral 
and  oral  forms  suggested  an  evaluation  of  this 
agent  not  only  in  essential  hypertension  but  also 
in  the  toxemias  of  pregnancy.  Vergitryl  by  the 
oral  route  of  administration  has  been  used  in  the 
treatment  of  essential  hypertension.  In  patients 
treated  continuously  for  periods  of  6 months  to 
more  than  1 year  the  drug  appears  to  be  at  least 
as  effective  and  no  more  toxic  than  other  avail- 
able Veratrum  preparations.  The  details  of  this 
study  will  be  reported  elsewhere. 

The  purpose  of  the  present  communication  is 
to  report  on  the  use  of  Vergitryl  in  the  manage- 
ment of  toxemias  of  pregnancy.  Various  reports 
have  appeared  concerning  the  beneficial  effects 
of  Veratrum  viride  in  the  hypertensive  toxemias 
of  pregnancy.^’  ^ However,  the  use  of  crude  ex- 
tracts did  not  permit  standardization  of  dosages, 
and  undesirable  side-effects  were  freciuent.  The 
purpose  of  this  report  is  to  call  attention  to  the 
apparently  greater  predictability  of  response  and 

* From  the  Georgetown  University  Medical  Service  and 
the  Georgetown  and  George  W’ashington  University  Obstetri- 
cal Services,  Gallinger  Municijjal  Hosj)ital,  and  the  George- 
town University  School  of  Medicine,  W^ashington,  I).  C. 

t This  investigation  was  supported  in  part  by  research 
grants  from  the  Xational  Heart  Institute  of  the  National 
Institutes  of  Health,  the  Sriuibb  Institute  for  .Meflical  Re- 
search, New  York  City,  and  Irwin,  Neisler  and  Comi)any, 
Decatur,  Illinois. 

f Sup|)licd  by  H.  Sidney  Newcomer,  M.I).,  F.  K.  Sriuibb 
and  Sons,  New  York  Citj’. 


FRANK  A.  FINNERTY,  JR.,  M.D. 

Chief  Resident  in  Medicine,  Georgetown  University  Medical  Ser- 
vice, Gallinger  Municipal  Hospital 

EDWARD  D.  FREIS,  M.D. 

Clinical  Adjunct  Professor  of  Medicine,  Georgetown  University 
School  of  Medicine 


the  diminished  incidence  of  major  side-effects 
when  the  purified  preparation  is  used. 

Methods  and  Results 

Preliminary  observations  indicated  that  the 
majority  (95  per  cent)  of  toxemic  patients  ex- 
hibit a definite  fall  in  blood  pressure  with  mini- 
mal or  no  side-effects  following  an  intramuscular 
dose  of  0.75  unit  of  Vergitryl.  This  circumvents 
the  technically  difficult  and  time-consuming  pro- 
cedure of  titrating  each  patient  separately  as  is 
necessary  in  the  technic  of  continuous  intra- 
venous administration  of  the  crude  extracts.^ 
Therefore,  all  nonconvulsive  patients  were  given 
this  dosage  initially.  The  drug  was  mixed  with  1 
c.c.  of  1 per  cent  procaine  in  order  to  prevent 
local  pain.  Recent  evidence  with  the  use  of  other 
local  anesthetics  suggests  that  procaine  also  in- 
hibits the  develoj)ment  of  nausea  and  vomiting. 
The  blood  pressure  and  pulse  rate  were  recorded 
every  half  hour,  and  whenever  the  blood  pres- 
sure rose  above  140,  90  mm.  Hg  the  dosage  was 
repeated,  thus  permitting  the  adoption  of  a 
routine  dosage  schedule.  In  the  occasional  case 
in  which  no  decrease  in  arterial  pressure  occurred 
1 hour  after  the  initial  dose  of  0.75  unit  (0.05  c.c.) 
of  Vergitryl,  it  was  increased  to  0.9  unit  (0.6  c.c.) 
and  if  necessary  at  the  end  of  an  additional  hour 
to  1.05  units  (0.7  c.c.)  until  an  effective  dosage 
was  obtained.  If  nausea  or  vomiting  occurred  it 
was  treated  immediately  with  50  mg.  of  pento- 
barbital sodium  given  intravenously. 


75 


76 


Vergitryl — Finnerty  and  Freis 


FEBRUARY,  1952 


In  17  cases  of  moderate  to  severe  preeclampsia 
the  hypertension  and  symptoms  of  toxemia  were 
quickly  controlled  following  the  use  of  Vergitryl 
in  all  cases.  In  cases  of  mild  preeclampsia  similar 
results  were  obtained.  Of  15  patients  who  had  a 
past  history  of  essential  hypertension  and  a 
superimposed  toxemia,  13  exhibited  reduction  of 
blood  pressure  to  140 '^90  mm.  Hg  or  less  and 
clearing  of  signs  and  symptoms.  Of  46  patients 
who  exhibited  elevation  of  blood  pressure  in  the 
early  postpartum  period  (so-called  postpartum 
preeclampsia)  44  responded  promptly  to  the  use 
of  Vergitryl  with  reductions  of  arterial  pressure  to 
the  normal  range. 

It  was  apparent,  therefore,  that  Vergitryl,  usu- 
ally given  in  a standard  dose  of  0.75  unit  intra- 
muscularly, produced  a prompt  fall  in  arterial 
pressure  to  the  normal  range  with  accompanying 
clinical  improvement  as  manifested  by  subsid- 
ence of  edema,  albuminuria  and  retinal  angio- 
spasm in  the  majority  of  cases  of  nonconvulsive 
toxemias.  Repeated  doses  of  the  drug  could  be 
given  as  often  as  once  per  hour  when  necessary 
to  maintain  the  hypotensive  effect,  although  the 
usual  interval  between  doses  was  3 to  4 hours. 
Severe  toxic  reactions  were  not  seen,  and  nausea 
and  vomiting  occurred  in  only  1 1 per  cent  of  the 
cases.  There  were  no  cases  of  maternal  or  fetal 
mortality  in  the  series. 

In  the  convulsive  or  eclamptic  toxemias  the 
intravenous  route  of  administration  was  utilized 
in  order  to  obtain  an  immediate  effect.  The  de- 


tails of  the  method  of  administration  will  be 
published  elsewhere.  In  8 patients  so  treated  the 
convulsions  were  promptly  controlled,  and  the 
blood  pressure  was  reduced  in  all  cases.  A living 
fetus  was  obtained  in  7 cases.  Moderate  nausea 
and  vomiting  occurred  in  every  case  treated  by 
the  intravenous  method  but  could  be  controlled 
by  giving  pentobarbital  sodium  intravenously. 
There  was  no  maternal  mortality. 

Summary 

The  availability  of  a highly  purified,  well 
standardized  extract  of  Veratrum  viride  (Ver- 
gitryl) has  simplified  the  management  of  the 
hypertensive  toxemias  of  pregnancy.  In  compari- 
son with  the  crude  extracts  its  advantages  are  (1) 
predictable  responses  to  standard  dosages  rather 
than  individual  titration  of  each  patient,  and  (2) 
administration  by  the  intramuscular  rather  than 
by  the  continuous  intravenous  route  in  all  except 
the  convulsive  cases. 

BIBLIOGR.\PHY 

1.  Rubin,  B.,  .\nd  Burke,  J.  C.,  in  .\bstracls  of  papers  pre- 

sented at  the  fall  meeting  of  the  .\merican  Society  for 
Pharmacology  and  Experimental  Therapeutics,  Inc.  in 
Omaha,  Nebr.,  1951. 

2.  Bry.cnt,  R.  D.,  .cnd  Fleming,  J.  G.;  Veratrum  viride  in 

treatment  of  eclampsia.  J.  .\.  M-  -V.,  1940,  115,  1353. 

3.  .\SSALI,  N.  S.;  Studies  on  Veratrum  viride;  standardization 

of  intravenous  technic  and  its  clinical  application  in 
treatment  of  toxemia  of  pregnancy.  Am.  J.  Obst.  & 
Gynec.,  1950,  60,  387. 


FACTORS  IN  THE  SELECTION  OF  CASES  FOR 
SURGERY  ON  THE  HEART  VALVES^ 

E.  COWLES  ANDRUS,  M.D.,  E.AC.P. 

Associate  Professor  of  Medicine,  Johns  Hopkins  University  School 
of  Medicine 


C N ABOUT  10  per  cent  of  cases  of  rheu- 

matic heart  disease  endocarditis  results  in  the 
development  of  “pure”  mitral  stenosis.  In  an  un- 
determined but  significant  proportion  of  such 
instances  the  person  leads  a normal  or  only 
slightly  restricted  life  for  its  usual  span.  Opera- 
tion, therefore,  is  not  indicated  in  patients  who 
display  no  more  than  the  typical  physical  signs 
of  mitral  stenosis.  In  the  majority,  however,  and 
most  commonly  among  women,  pulmonary  en- 
gorgement becomes  progressive  and  disabling, 
usually  during  the  fourth  or  fifth  decade  of  life. 

Within  the  past  5 years  interest  has  revived  in 
the  surgical  treatment  of  mitral  stenosis. 
Methods  have  been  widely  and  successfully  ap- 
plied to  enlarge  the  mitral  orifice  either  by 
cutting  or  tearing  along  the  fused  valve  com- 
missures. Operative  mortality  has  been  12  per 
cent  or  less.  Relief  has  sometimes  been  dramatic; 
great  improvement  has  been  accomplished  in  well 
over  half  the  patients,  and  disability  has  been 
reduced  in  many  others.  Although  the  morpho- 
logic features  of  the  damaged  valve  cusps  and 
chordae  tendineae  affect  the  local  success  of  the 
surgical  procedure,  the  circulatory  results  de- 
pend largely  upon  the  selection  of  cases  for 
operation. 

Indications 

The  indications  for  surgical  treatment  of  mitral 
stenosis  derive  directly  from  its  dynamic  conse- 
quences. Increased  pressure  in  the  left  auricle, 
referred  back  through  the  valveless  pulmonary 
veins,  is  reflected  in  altered  conditions  of  pressure 

* .Ahriclgment  of  [)aper  delivered  at  the  Twenty-second 
Annual  Scientific  Assembly  of  the  Medical  Society  of  the 
District  of  Columbia,  October  1,  1951. 


and  flow  in  vital  areas  of  the  pulmonary  circu- 
lation. The  reserve  capacity  of  the  pulmonary 
vessels  is  normally  considerable;  blood  flow  may 
be  increased  several  fold  without  significant  signs 
of  engorgement  or  elevation  of  pulmonary 
arterial  pressure.  With  mitral  stenosis  the  avail- 
able vascular  channels  in  the  lungs  are  already 
more  completely  filled  at  rest,  and  pressure 
within  these  vessels,  notably  in  the  pulmonary 
capillaries,  rises  with  effort  or  excitement.  When 
hydraulic  pressure  in  these  capillary  vessels  ex- 
ceeds a critical  level,  pulmonary  edema  results  as 
fluid  escapes  into  pericapillary  spaces  in  the 
alveolar  walls.  When  this  condition  becomes  fre- 
cjuent  or  persistent  respiratory  function  is  locally 
impaired.  When  it  is  widespread  the  elasticity  of 
the  turgid  lung  is  reduced  and  the  reflex  stimulus 
to  hyperventilation  with  exercise  is  exaggerated. 
With  long-standing  engorgement  of  the  lungs 
pulmonary  vascular  resistance  is  increased. 

Symptoms  of  pulmonary  engorgetnent — dyspnea. 
Most  helpful  for  the  evaluation  of  the  patients’ 
circulatory  status  is  their  description  of  their 
limits  of  comfortable  activity.  Occasionally  these 
change  only  gradually.  More  commonly  after 
many  years  without  restricting  discomfort, 
during  which  women  patients  may  have  gone 
through  several  pregnancies  without  significant 
circulatory  embarrassment,  distressing  breath- 
lessness, often  accompanied  by  cough,  becomes 
progressively  more  severe.  Iwentually  paro.xysms 
of  dyspnea  interrupt  sleej)  at  night  and  addi- 
tional pillows  are  necessary  for  comfort. 

Pulmonary  edema.  What  has  been  said  of 
dyspnea  as  a manifestation  of  circulatory  disa- 
bility applies  as  well  to  transient  attacks  of 
pulmonary  edema.  C'haracteristically  these  occur 


77 


78 


Surgery  on  Heart  Valves — Andrus 


FEBRUARY,  1952 


following  effort  or  excitement  and  are  accom- 
panied by  signs  of  moisture  in  the  air  passages  or 
the  raising  of  foamy,  pink  sputum.  In  patients 
with  mitral  stenosis  this  is  not  evidence  of  left 
ventricular  failure  but  of  engorgement  in  the 
functional  area  of  the  pulmonary  capillaries  pro- 
voked by  the  relatively  too  efficient  right 
ventricle.  Indeed,  when  the  right  ventricle  fails 
after  persistent  increase  in  pulmonary  vascular 
resistance  or  sometimes  with  the  onset  of  auricu- 
lar hbrillation,  pulmonary  edema  may  not  recur. 

Hemoptysis.  Pulmonary  infarction,  with  spu- 
tum containing  dark  blood  or  clots,  may  occur 
following  embolism  from  the  right  auricle  in  the 
presence  of  auricular  fibrillation,  or  due  to  local 
thrombosis  of  vessels  in  the  congested  lung.  Usu- 
ally these  are  late  manifestations  of  disease 
and  when  accomjianied  by  other  embolic  phe- 
nomena or  by  right  heart  failure  are  cause  for 
caution  in  recommending  operation.  Frank  he- 
moptysis, on  the  other  hand,  producing  relatively 
large  amounts  of  bright  red  blood,  is  a most 
urgent  indication.  Such  attacks  may  occasion- 
ally follow  effort  but  are  not  commonly  accom- 
panied by  other  signs  of  pulmonary  congestion. 
The  sources  of  bleeding  are  evidently  one  or 
more  varices  of  the  bronchial  veins  which  afford 
collateral  channels  between  the  pulmonary  and 
systemic  venous  systems.  Such  hemoptyses  are 
signs  of  critical  rise  of  pulmonary  venous  pres- 
sure relative  to  that  in  the  systemic  (azygos) 
veins,  and  of  fragile  collateral  vessels.  Attacks 
tend  to  become  more  frecpient  and  bleeding  more 
profuse. 

Results  of  cardiac  catheterization.  Physiologic 
data  gathered  by  cardiac  catheterization  are 
helpful  but  not  essential  aids  in  predicting  the 
likelihood  of  circulatory  relief.  Cardiac  output 
so  determined  is  usually  diminished  at  rest  and 
fails  to  increase  with  mild  exercise  as  in  normal 
persons.  Pulmonary  arterial  pressure  is  meas- 
urably elevated,  occasionally  above  the  level  of 
that  in  the  systemic  arteries,  and  rises  sharply 
with  exercise.  Pulmonary  “capillary”  pressure 
(recorded  with  the  tip  of  the  catheter  in  a ter- 
minal branch  of  the  ])ulmonary  artery)  is  usually 


high.  The  pattern  of  pressure  most  favorable  to 
pronounced  postoperative  benefit  consists  of 
raised  “capillary”  pressure  without  excessive  el- 
evation of  pulmonary  artery  pressure,  suggesting 
that  pulmonary  artery  vascular  resistance  has 
not  become  high,  and,  by  implication,  irrevers- 
ibly fixed.  Arterial  oxygen  saturation  is  usually 
normal  at  rest  but  often  falls  with  exercise  as 
pulmonary  blood  flow  fails  to  increase  to  meet 
the  new  demands.  Diminished  resting  arterial 
oxygen  saturation  suggests  that  changes  in  the 
alveolar  walls  secondary  to  chronic  capillary  con- 
gestion interfere  with  diffusion;  it  cannot  be 
assumed  that  this  function  will  be  restored  even 
though  operation  relieves  the  mitral  obstruction. 

In  evaluating  the  signiflcance  of  symptoms 
and  signs  as  indications  for  surgical  treatment 
of  mitral  stenosis  it  is  most  important  to  iden- 
tify other  contributing  factors  and,  from  the 
patient’s  story  and  by  direct  observation,  to  ap- 
praise the  rate  of  progress  of  disability  as  well 
as  its  degree.  Occasionally  this  may  be  a slow 
process  occupying  many  years.  More  commonly 
a patient  may  pass  from  a state  without  signifi- 
cant discomfort  to  severe  disability  within  a 
year  or  two  or  even  less.  Sometimes  this  may  be 
accounted  for  by  the  establishment  of  auricular 
fibrillation.  Sometimes  persistently  increased 
erythrocyte  sedimentation  rate,  leukocytosis,  or 
mild  fever  suggest  continuing  activity  of  rheu- 
matic disease.  And,  in  the  advanced  stages  of 
disability  signs  of  right  heart  failure  (congestion 
of  systemic  veins,  hepatic  enlargement  or  periph- 
eral edema)  indicate  that,  due  to  long-standing 
engorgement,  pulmonary  vascular  resistance  has 
become  fixed  at  a high  level. 

Contraindications 

Active  rheumatic  disease.  .Although  fever,  leuko- 
cytosis, or  elevated  sedimentation  rate  may  be 
due  to  other  causes  in  these  patients,  unless  the 
alternative  cause  can  be  clearly  identified  cau- 
tion dictates  that  the  rheumatic  state  and  pre- 
sumably carditis  be  assumed  to  persist.  Some  of 
the  tragedies  attending  the  operative  treatment 


VOL.  XXI,  NO.  2 


Medical  Annals  of  the  District  of  Columbia 


79 


of  mitral  stenosis  have  evidently  been  due  to 
exacerbation  of  rheumatic  carditis. 

Acute  bacterial  endocarditis.  This  is  an  obvious 
contraindication.  Operation  upon  patients  in 
whom  the  disease  has  been  cured  by  antibiotic 
therapy  involves  some  potential  risk  that  viable 
bacteria  enclosed  within  the  healed,  scarred  valve 
may  reawaken  the  local  infection.  Adequate  ex- 
perience is  lacking  but  a few  such  patients  have 
undergone  mitral  surgery  and,  so  far,  bacterial 
endocarditis  has  not  been  a prominent  postoper- 
ative complication. 

Intractable  right  heart  failure.  When  the  right 
heart  becomes  overburdened  and  dilates  in  the 
face  of  long-maintained  high  pulmonary  vascu- 
lar resistance,  and  signs  of  congestive  failure  with 
hepatic  engorgement  appear  and  persist  despite 
rest  and  the  administration  of  digitalis  and  diu- 
retics, circulatory  disability  has  probably  reached 
an  irreversible  stage.  In  response  to  the  patient’s 
urgent  plea,  and  lacking  effective  alternative 
treatment,  some  operations  have  been  under- 
taken under  these  circumstances,  but  the  mor- 
tality is  discouragingly,  if  not  prohibitively,  high. 

Embolism.  Auricular  fibrillation  is  not  a con- 
traindication in  itself,  but  when  long  established 
it  contributes  to  the  hazard  of  embolism.  There 
is  no  certain  means  to  identify  mural  thrombi 
prior  to  operation,  but  history  of  recent  or  fre- 
quent embolic  phenomena  sharply  increases  the 
risk  of  postoperative  embolism.  This  has  oc- 
curred in  3 to  5 per  cent  of  the  cases. 

Mitral  insufficiency.  Given  the  typical  physi- 
cal signs  of  mitral  regurgitation  its  influence 
upon  the  circulatory  dynamics  in  any  case  is 
difficult  to  appraise.  Enlargement  of  the  left 
ventricle  is  more  commonly  evident  with  the 
combined  defects  than  with  mitral  stenosis  alone. 
.\ny  considerable  enlargement  of  the  left  auricle 
suggests  accompanying  mitral  insufficiency, 
particularly  if  dilatation  of  the  auricle  with  ven- 
tricular systole  can  be  demonstrated  by  fluor- 


oscopy or  by  roentgenkymography.  Concern  re- 
garding mitral  insufficiency  in  these  cases  is  based 
upon  the  apprehension  that  surgical  relief  of  the 
obstructive  narrowing  of  the  orifice  may  only 
enhance  the  adverse  circulatory  effects  of  re- 
gurgitation. 

Lesions  of  other  valves.  Few  patients  with  mul- 
tiple valve  lesions  have  undergone  operation. 
On  theoretical  grounds  an  obstructive  lesion  at 
the  aortic  valve  would  seriously  compromise  the 
benefit  of  valvulotomy  for  mitral  stenosis.  Fol- 
lowing relief  of  mitral  obstruction  in  such  cases 
a larger  proportion  of  the  ventricular  contents 
would  flow  back  through  the  inflow  tract  with 
systole  than  through  the  obstructed  aortic  orifice. 

Summary 

The  selection  of  cases  of  mitral  stenosis  in 
which  favorable  results  may  be  expected  from 
surgical  treatment  rests  primarily  upon  appraisal 
of  the  dynamic  consequences  of  mitral  obstruc- 
tion. 

Indications  are  the  symptoms  and  signs  of 
disabling  engorgement  of  the  pulmonary  circula- 
tion: (1)  progressively  severe  dyspnea  on  exertion 
or  excitement,  (2)  cough  or  pulmonary  edema 
following  effort  or  excitement,  (3)  paroxysmal 
dyspnea  at  rest  (often  at  night),  (4)  orthopnea, 
and  (5)  hemoptysis. 

By  no  means  all  individuals  with  the  physical 
signs  of  mitral  stenosis  require  surgical  relief. 
However,  experience  indicates  that  the  likeli- 
hood of  striking  benefit  diminishes  as  the  dura- 
tion of  the  above  symptoms  lengthens.  Opera- 
tion should,  therefore,  be  advised  as  soon  as 
progressing  disability  becomes  manifest. 

Contraindications  are  (1)  active  rheumatic  car- 
ditis, (2)  bacterial  endocarditis,  (3)  intractable 
right  heart  failure,  (4)  freciuent  or  recent  em- 
bolism, (5)  mitral  insufficiency,  and  16)  lesions 
of  other  valves,  particularly  aortic  stenosis. 


ELEMENTS  OF  PSYCHOTHERAPY  IN  GENERAL 
MEDICAL  PRACTICE 


^/_HE  ELEMENTS  of  psychotherapy  are 

^ as  old  as  the  practice  of  medicine  and,  in 
some  form,  have  always  been  an  important  part 
of  the  professional  skill  of  the  good  physician. 
The  capacity  to  reduce  the  [patient’s  anxiety, 
panic,  or  despair  in  his  illness  and  to  create  a 
hopeful  or  even  confident  cooperation  has  always 
been  a quality  of  the  respected  doctor  of  medi- 
cine; indeed  it  has  always  been  one  of  the  import- 
ant reasons  for  the  respect  itself  and  has  been  no 
small  part  of  the  secret  of  his  success  in  the  heal- 
ing art.  Some  skill  in  psychotherapy  is  entirely 
inseparable  from  the  skillful  practice  of  medicine. 
In  recent  years  psychotherapy  has  been  further 
developed  and  emphasized  as  a special  skill  and 
special  field.  The  technical  vocabulary  of  the 
specialist,  and  sometimes  his  attitude  as  well, 
may  have  the  unfortunate  effect  of  making  the 
nonspecialist  feel  like  an  unskilled  intruder.  ITis 
is  particularly  unfortunate  when  the  field  is  as 
broad  and  inclusive  as  that  of  psychologic  factors 
in  illness  and  in  recovery,  elements  which  are 
common  to  the  whole  of  medicine. 

Systematic  consideration  of  psychotherapy 
makes  it  possible  to  formulate  some  of  the  psy- 
chologic factors  implicit  in  medical  treatment, 
and  to  suggest  certain  princij^les  and  practices 
for  the  mental  hygiene  of  medical  treatment. 
Some  of  these  may  be  stated  as  follows: 

The  sick  person  is  usually  fearful  or  anxious, 
and  the  relief  of  anxiety  is  usually  a primary  ob- 
jective of  psychotherapy.  Aside  from  the  direct 
and  understandable  (although  often  exagger- 
ated) fear  of  chronic  illness  or  death,  illness  often 
creates,  and  even  more  frequently  reawakens  or 
intensifies,  other  fears  or  anxieties.  Eor  example, 
the  man  may  fear  the  loss  of  his  job,  particularly 
if  there  w as  some  preexisting  sense  of  inadequacy. 


RICHARD  L.  JENKINS,  M.D. 

Chief,  Research  Section,  Psychiatry  and  Neurology  Division,  De- 
partment of  Medicine  and  Surgery,  Veterans  Administration 


or  the  woman  the  breakup  of  her  home  as  a re- 
sult of  the  incapacity  occasioned  by  the  illness. 
Such  fears  may  effectively  block  treatment  by 
rendering  the  patient  unwilling  to  abide  by  med- 
ical direction  concerning  rest,  for  example.  It  is 
not  for  the  physician  to  transfer  to  the  patient 
the  full  responsibility  for  a resulting  therapeutic 
failure.  The  Eather  of  Medicine  himself  defined 
medical  responsibility  more  broadly  in  his  first 
aphorism : 

“Life  is  short,  and  the  Art  long;  the  occasion  fleeting; 
experience  fallacious,  and  judgment  difficult.  The  physi- 
cian must  not  only  be  prepared  to  do  what  is  right  him- 
self, but  also  to  make  the  patient,  the  attendants,  and 
the  externals  cooperate.” 

Since  the  physician  has  only  moral  authority, 
he  cannot  force  the  cooperation  of  the  patient, 
but  must  win  it.  L^nderstanding  the  psychology 
of  the  patient  is  a part  of  the  responsibility  of 
the  physician  no  less  than  understanding  the 
disease  which  affects  him. 

d'he  physician  should  not  ov'erlook  the  fre- 
quency with  which  patients  tend  to  feel  their 
illness  to  be  a punishment  for  some  deficiency 
of  conduct  or  thought.  This  is  particularly  likely 
to  be  the  case  with  insecure,  worrisome  per- 
sonalities in  conflict  and  anxiety  over  their  own 
impulses.  Even  in  illness  which  cannot  be  con- 
sidered in  any  reasonable  sense  psychogenic  or 
psychosomatic  the  psychologic  state  of  the  pa- 
tient is  always  an  important,  and  frequently  a 
determining,  factor  in  recovery. 

The  dispelling  of  unjustified  fears,  the  reduc- 
tion of  morbid  anxiety,  and  the  encouragement 
in  the  patient  of  some  justified  confidence  in  his 
receiving  help  should  be  a primary  objective  of 
the  physician. 


80 


VOL.  XXI,  NO.  2 


Medical  Annals  of  the  District  of  Columbia 


81 


Scarcely  less  important  to  the  patient  than 
the  preservation  of  his  life  is  the  independence 
of  his  personality.  An  approach  which  shows  re- 
spect for  the  patient’s  personality  generally  wins 
cooperation,  and  an  approach  which  shows  no 
respect  for  personality  may  lose  cooperation  even 
though  the  patient  believes  his  life  is  jeopard- 
ized by  that  lack  of  cooperation. 

.Although  it  is  not  desirable  that  the  physician 
regulate  his  treatment  primarily  according  to  the 
wishes  of  the  patient,  since  to  do  so  would  be  to 
abdicate  his  professional  role,  yet  it  is  of  the 
greatest  importance  that  he  understand  what  the 
patient’s  strong  desires  are  and  treat  them  with 
respect.  The  patient’s  desire  to  determine  his 
own  actions  is  especially  important.  Sympathetic 
explanation  of  the  reason  for  necessary  restric- 
tions and  their  probable  duration  will  go  far 
toward  reducing  tension  about  them  and  winning 
cooperation.  If  the  patient  challenges  the  advice, 
the  physician  may  sometimes  advantageously 
e.xplain  that  he  is  not  seeking  to  make  life  de- 
cisions for  the  patient  but  merely  seeking  to  do 
his  job  as  a good  physician,  and  refer  back  to  the 
patient  in  a kindly  manner  the  question  of  the 
wisdom  of  taking  medical  advice.  The  physician 
should  seek  to  maintain  his  position  as  a pro- 
fessionally trained  person  offering  help  rather 
than  permit  himself  to  be  cast  in  the  role  of  a 
forbidding  policeman. 

In  general,  whenever  a patient  shows  signs  of 
feeling  too  pressed  or  hemmed  in  by  the  physi- 
cian, the  latter  should  consider  whether  the  [)a- 
tient  may  not  be  most  benefited  by  a release  of 
this  pressure  by  a kindly  discussion  embodying 
the  attitude  on  the  part  of  the  physician:  “This 
is  your  decision.  It  is  up  to  you.  Let  us  talk  about 
what  the  results  of  different  courses  of  action 
are  likely  to  be.”  Such  an  approach  if  honestly 
given  and  not  with  a tone  of  impatience  is 
usually  accepted  by  the  patient  and  very  fre- 
quently results  in  a change  of  attitude  from  re- 
sistance to  external  pressure  to  a {)ersonal 
assum{)tion  of  responsibility  in  the  matter  at 
hand. 


If  the  patient  accepts  the  desirability  of  follow- 
ing medical  advice  but  protests  that  in  this  in- 
stance it  is  impossible  or  too  difficult  for  him  to 
do  so,  this  may  well  be  the  basis  for  further  dis- 
cussion of  what  problems  or  experiences  make  it 
difficult  or  impossible  for  him.  Objections  may 
be  due  to  misunderstandings,  misapprehensions 
or  emotional  ways  of  looking  at  the  requirements 
which  may  soften  or  disappear  under  a little 
kindly  discussion.  Or  the  physician  may  find 
some  way  of  achieving  his  therapeutic  objective 
which  by-passes  particular  elements  to  which 
the  patient  objects. 

In  dealing  with  the  psychotic  patient  who 
needs  hospitalization  the  physician  must  very 
frequently  support  the  relatives  in  their  reach- 
ing a decision  to  hospitalize  the  patient  against 
his  will.  Relatives  are  often  understandably  re- 
luctant to  do  so,  and  may  need  a good  deal  of 
firm,  kindly  support.  They  may  need  to  talk 
about  it  and  may  require  a little  time  to  adjust 
themselves  to  the  idea.  Either  lack  of  firmness 
in  advice  that  this  course  is  wise  and  necessary 
and  to  the  best  interest  of  the  patient,  or  lack  of 
an  attitude  of  kindly  understanding  may  result 
in  their  failure  to  follow  the  advice,  in  the  first 
instance  because  the  necessity  has  not  been  made 
absolutely  clear,  and  in  the  latter  because  the 
feeling  of  betrayal  of  family  loyalty  aroused  in 
many  persons  in  relation  to  forcing  the  hospitali- 
zation of  a member  of  the  family  is  not  ade- 
quately managed.  'Fhe  physician  can  escape 
moral  responsibility  for  tragic  results  of  a failure 
to  follow  his  advice  only  if  he  has  shown  full  pro- 
fessional diligence  and  skill  in  giving  the  advice 
in  the  way  most  likely  to  insure  its  acceptance. 

Release  of  inner  tension  is  another  important 
element  in  psychotherajiy.  Encouraging  the  pa- 
tient to  talk  about  his  {)roblems  is  often  a very 
valuable  means  for  the  release  of  tension.  The 
patient  who  has  bottled  up  his  resentment  to- 
ward, for  example,  a superior  or  a spouse,  may 
after  relieving  himself  by  an  exi)ression  of  anger 
be  in  a much  more  flexible  and  cooperative 
frame  of  mind  and  may  spontaneously  shift  his 


82 


Psychotherapy  in  General  Practice — Jenkins 


FEBRUARY,  1952 


attention  from  what  he  has  been  objecting  to, 
to  what  he  can  do  to  improve  the  situation,  some- 
times with  an  amused  and  tolerant  assumption 
of  some  previously  unrecognized  responsibility. 

The  relief  of  excessive  feelings  of  guilt  or  of 
inadecjuacv  is  a widely  important  element  of 
psychotherapy,  particularly  in  psychoneurotic 
patients.  It  is  achieved  particularly  by  the  un- 
derstanding and  accepting  attitude  of  the  phy- 
sician. As  he  gains  confidence  in  the  physician  the 
patient  is  usually  increasingly  willing  to  tell  those 
things  which  have  caused  him  self-blame  and 
guilt-anxiety.  Usually  in  psychoneurotic  patients 
these  elements  are  lesser  rather  than  greater, 
relatively  usual  human  failures  and  shortcom- 
ings, thoroughly  understandable,  and  not  justi- 
fying the  extent  of  the  patient’s  emotional  re- 
action. The  physician  should  be  careful  not  to 
intrude  his  personal  value-judgments  incau- 
tiously. For  example,  it  is  wise  to  treat  the  value- 
judgments  arising  from  the  religious  beliefs  of 
the  patient  with  the  greatest  respect,  although 
this  implies  no  need  to  neglect  those  opportu- 
nities afforded  by  raising  questions  when  the  pa- 
tient has  misinterpreted  teachings  of  his  religion 
or  is  seeking  to  apply  them  in  distorted  ways. 
When  such  problems  arise  there  is  often  value 
in  referring  the  patient  to  a religious  counselor 
of  his  faith. 

The  mere  fact  that  the  patient’s  actions  and 
feelings  can  be  understood  and  accepted  by  the 
physician  may  go  far  toward  relieving  a morbid 
sense  of  guilt  or  inadecjuacy.  The  reexamination 
by  the  patient  of  his  own  values  which  commonly 
results  usually  leads  to  a better  emotional  per- 
spective. The  physician  should  be  aware  that 
deeply  ingrained  feelings  are  as  a rule  modified 
but  slowly.  He  should  avoid  the  unjustified  pes- 
simism of  concluding  that  such  attitudes  are  un- 
modifiable  and  the  equally  unjustified  optimism 
of  believing  they  can  be  removed  l)y  superficial 
reassurance  and  a pep  talk. 

d'he  neurotic  patient  especially  is  typically 
torn  by  desires  or  impulses  of  which  he  is  un- 
conscious. This  is  by  reason  of  the  fact  that 
such  desires  and  impulses  are  in  conflict  with 


his  conception  of  himself  as  he  is  or  should  be, 
and  are  repressed.  While  the  deej^er  exploration 
of  the  unconscious  is  a task  for  the  specialist, 
any  physician  should  have  some  awareness  of 
the  contradictions  and  vagaries  of  human  moti- 
vation, and  some  capacity  to  accommodate  him- 
self to  them.  For  example,  the  overanxious,  over- 
solicitous,  overconcerned  mother  or  spouse  is 
frequently  recognizable  to  any  wise  observer  as 
a person  pushing  out  of  her  mind  strong  feelings 
of  resentment  at  the  burdens  of  care  of  the  pa- 
tient and  proving  to  herself  and  the  world  what 
a good  mother  or  wife  she  is.  Or  the  physician 
may  recognize  in  the  appreciative  patient  who 
carries  out  his  instructions  to  the  letter  a de- 
pendence upon  the  physician  which  the  patient 
does  not  wish  to  give  up,  and  which  may  create 
an  obstacle  to  his  recovery. 

The  physician  should  use  such  realizations 
with  discretion.  No  good  and  much  harm  is 
likely  to  result  from  charging  the  oversolicitous 
mother  or  wife  with  resentment  of  the  burden  of 
the  patient,  but  some  recognition  of  her  need  for 
appreciation  of  her  sacrifice  and  for  reassurance 
may  be  helpful.  The  dependent  patient  can  be 
gently  encouraged  to  a self-confidence  in  which  he 
outgrows  his  need  for  dependence.  Such  transi- 
tions occur  only  slowly.  The  secondary  gains  of 
illness  may  be  protecting  the  patient  from  return 
to  a life  situation  to  which  he  feels  unequal,  and 
change  in  that  situation  or  in  his  own  sense  of 
adecpiacy  may  be  necessary  to  recovery. 

The  development  of  insight  commonly  occurs 
as  the  ])atient  becomes  sufficiently  relieved  of 
his  tensions  and  anxieties  to  get  a new  perspec- 
tive on  his  problem.  The  development  of  insight 
is  the  emergence  of  a new  perspective  on  the 
problem  through  which  the  patient  better  under- 
stands himself  and  his  own  actions. 

In  the  process  of  reflection  by  the  patient  with 
the  encouraging  support  of  the  physician,  a new 
understanding  of  himself  and  his  life  situation 
develops  in  the  patient  and  provides  a more  suit- 
able framework  for  intelligent  action  than  his 
hitherto  overanxious,  perple.xed  or  defeatist  view. 
This  change  may  be  promoted  by  interpretive 


VOL.  XXI,  NO.  2 


Medical  Annals  of  the  District  of  Columbia 


83 


suggestion  liy  the  j)hysician  when  these  sugges- 
tions are  phrased  in  language  and  thought  ac- 
ceptable to  the  patient,  and  when  the  patient  is 
ready  for  them.  The  consideration  by  physician 
and  patient  of  what  elements  of  the  patient’s 
past  experience  have  led  him  to  take  the  particu- 
lar view  that  he  does  is  commonly  a most  useful 
means  toward  aiding  the  patient  to  gain  a new 
perspective  on  himself  and  his  life-situation. 

The  fostering  of  courage  and  healthy  self- 
belief is  of  the  greatest  importance.  It  is  fre- 
quently a spontaneous  result  of  gaining  insight, 
because  with  insight  what  appears  as  an  insolu- 
ble problem  often  becomes  soluble.  The  self- 
reliant  patient  may  need  conhdence  in  the  phy- 
sician only  briefly,  although  even  here  we  should 
recognize  that  the  man  with  full  confidence  in 
one  life-situation  may  lack  confidence  in  another. 

Self-belief  also  depends  in  part  upon  the  belief 
in  others  and  in  part  upon  the  experience  of  suc- 
cess. The  physician’s  confidence  in  his  patient 
is  important  as  is  his  helping  the  patient  to  break 
down  a task  he  has  felt  to  be  overwhelming  into 
a series  of  steps  which  may  be  mastered,  one 
after  another. 

It  is  this  fostering  or  rebuilding  of  self-belief 
which  gives  the  anxious  patient  courage  to  give 
up  the  support  of  the  physician  and  go  ahead 
on  his  own.  Treatment  is  incomplete  until  the 
confidence  of  the  patient  is  reasonably  restored. 

There  is  often  need  for  encouraging  a patient 
to  develop  new  avenues  of  satisfaction,  as  in 
golf,  tennis,  handwork  or  hobbies.  Such  satis- 
factions may  increase  the  resilience  of  the  per- 
sonality and  enable  him  successfully  to  manage 


situations  which  would  otherwise  become  in- 
tolerable. 

Certain  types  of  problems  should  be  referred 
to  the  specialist.  In  general  these  include  the 
psychoses,  at  least  the  pronounced  psychoneuro- 
ses, all  emotional  disturbances  of  an  intensity 
suggesting  the  risk  of  suicide,  homicide  or  other 
untoward  outcome,  the  addictions,  and  any  cases 
departing  widely  from  the  experience  of  the  non- 
specialist or  presenting  unusual  features.  The 
nonspecialist  should  be  particularly  aware  of  the 
frequency  with  which  physical  complaints  of 
health  are  the  presenting  complaints  of  a frank 
depression.  When  such  a patient  is  discharged 
from  the  hosjrital  and  goes  home  to  hang  himself, 
his  death  is  the  result  of  a medical  error  no  less 
than  would  have  been  the  case  had  he  died  as  a 
result  of  an  athletic  contest  he  was  permitted 
to  enter  with  a bad  heart. 

In  making  such  referral  the  physician  must  be 
careful  in  his  interpretation  to  the  patient.  Most 
patients  are  able  to  accept  an  interpretation  that 
emotional  factors  have  contributed  to  the  prob- 
lem and  deserve  exploration.  On  the  other  hand, 
the  patient’s  reaction  to  an  uninterpreted  re- 
ferral is  too  often  an  angry  or  defensive  senti- 
ment, expressed  or  unexpressed,  “So  you  think 
I’m  crazyj  Well,  you’re  crazy!’’ 

The  skillful  practice  of  medicine  in  any  field 
is  impossible  without  constant  utilization  of  the 
elements  of  psychotherapy.  These  are  not  new, 
although  they  have  been  more  systematically 
develoj)ed  in  recent  years.  They  cannot  be  re- 
garded as  the  sole  province  of  the  specialist,  al- 
though he  should  lie  expected  to  develop  a supe- 
rior skill  in  their  utilization. 


METASTATIC  MELANOMA  TO  THE  BLADDER  WITH 
POSSIBILITY  OF  BEING  PRIMARY  IN  THE 
THYROID  GLAND 

Report  of  a Case 

W.  C.\LH()UX  STIRLING,  M.D. 

OSCAR  B.  HUNTER,  JR.,  M.D. 

W ashington 


ELANOCARCINOIMA  of  the 
thyroid  gland  has  never  Vjeen  described  in  the 
literature.  Melanocarcinoma  in  the  negro  is  a very 
rare  lesion.  Only  8 such  cases  were  found  among 
3,000  melanomas  in  the  Tumor  Registry.  Meta- 
static lesions  were  observed  in  the  kidney,  but 
none  were  found  in  the  bladder.  Eor  these  reasons 
we  feel  that  a case  recently  observed  warrants  this 
report. 

Report  of  Case 

The  patient  was  an  ot)ese,  4M-year-old  colored  woman, 
who  had  lived  on  a farm  all  of  her  life.  In  June,  1948,  she 
noticed  a slight  swelling  in  the  neck,  most  marked  on  the 
right  side,  abov’e  the  sternocleidomastoid  muscle.  The 
mass  gradually  enlarged  but  produced  no  symptoms 
other  than  those  associated  with  the  size  of  the  mass. 
Because  of  the  fact  that  the  “goiter”  was  growing  larger, 
she  consulted  Dr.  J.  W.  Bird.  He  advised  a thyroidectomy 
which  was  performed  on  September  22,  1948. 

Grossly  the  specimen  consisted  of  a thyroid  mass, 
6 cm.  in  length,  4 cm.  in  width,  and  4 cm.  in  thickness. 
The  outer  surface  was  smooth,  and  on  section  the  central 
portion  contained  a dark  pigmented  mass  separated  by 
many  trabeculae. 

Microscopic  sections  through  the  tissue  revealed  a 
thin  rim  of  thyroid  tissue  around  the  outer  surface  of  the 
large  central  mass.  Within  the  rim  of  tissue  were  many 
flattened  acini  lined  by  flat,  cuboidal  epithelium,  contain- 
ing a small  amount  of  colloid.  Within  this  same  layer 
were  scattered  hemorrhages,  with  old  blood  pigment  and 
an  accumulation  of  chronic  inflammatory  cells.  This 
tissue  was  separated  from  the  larger  mass  by  a relatively 
thick-walled  capsule  of  fibrous  tissue.  The  central  mass 
was  composed  of  a number  of  different  types  of  cells. 
One  type  present  was  the  young  thyroid  cell,  forming 
nodules  of  fetal  adenomatous  tissue.  Scattered  between 
these  nodules  were  large  giant  cells  with  bizarre  nuclei. 


Their  cytoplasm  contained  melanin  pigment.  Other  cells 
were  small  and  compact  with  basophilic  nuclei.  In  still 
other  areas  the  cells  were  more  lu.xuriant  and  the  nuclei 
larger,  with  prominent  nucleoli  similar  to  those  seen  in 
melanocarcinoma  of  the  skin.  In  the  central  portion  of 
the  tumor  necrosis  was  observed  with  deposits  of  melanin 
pigment  remaining.  Sections  through  various  parts  of  the 
tumor  revealed  a similar  picture.  Considerable  variance 
in  the  amount  of  tumor  tissue  was  present  in  different 
areas.  The  number  of  mitotic  figures,  however,  was  rela- 
tively infrequent.  Iron  stains  were  negative,  and  bleach- 
ing processes  removed  the  pigment. 

This  is  an  e.xtremely  rare  tumor,  primarily  be- 
cause melanocarcinoma  is  rare  in  negroes  and 
secondly  because  of  its  being  an  isolated  lesion 
in  the  thyroid.  It  is  extremely  unusual  for  a 
melanocarcinoma  to  arise  as  a primary  lesion. 

Following  her  operation,  the  patient  was  again  e.xam- 
ined,  with  particular  emphasis  being  placed  on  possible 
sources  of  origin  of  the  tumor.  Surgery  had  not  been  per- 
formed prior  to  the  thyroidectomy.  Her  vision  was 
normal,  and  she  had  not  complained  of  headaches.  There 
was  no  history  of  any  oral  lesion,  gastrointestinal  diffi- 
culty, or  any  other  possible  associated  lesion.  No  skin 
lesions  or  pigmented  nevi  were  found,  and  the  skin  was 
an  even  chocolate  brown.  No  pigmented  areas  were  found 
in  the  mucous  membranes  of  the  nose  or  throat.  The 
vagina  and  rectum  were  examined,  and  nothing  ab- 
normal was  found.  A roentgenogram  of  the  chest  was 
normal.  -A  fundoscopic  examination  of  the  eyes  revealed 
no  abnormalities,  and  the  visual  fields  were  not  disturbed. 

The  patient  remained  symptom-free  for  6 months, 
when  profuse  bleeding  from  the  urinary  tract  was  noted 
for  the  first  time,  and  continued  for  4 weeks.  .\  cystoscopic 
examination  on  .April  22,  1949,  revealed  a dark,  pig- 
mented papillary  mass  (see  figure  1)  on  the  posterior 
wall  of  the  bladder,  approximately  2 cm.  superior  to  the 


84 


VOL.  XXI,  NO.  2 


Medical  Annals  of  the  District  of  Columbia 


85 


interureteric  ridge  in  the  midline.  Early  invasion  of  the 
wall  of  the  bladder  was  noted  after  the  tumor  had  been 
resected  through  the  urethra.  Clinically,  the  mass  was 
a pigmented  mole  and  quite  malignant.  Sections  from 
the  excised  mass  consisted  of  a number  of  pieces  of  dark 
tissue,  together  with  a few  small  nodules  of  white  tissue. 
The  pieces  were  1 cm.  in  diameter  as  an  average. 


‘.'7-''.  *.«  'Tt'x  ,v  > -.  V C > ■ '7 

. / ■ '5  . 


Fig.  1.  Section  through  bladder  wall  in  area  of  metastasis, 
showing  muscular  coat  being  infiltrated  by  large  vesicular 
tumor  cells.  Majority  of  cells  contain  no  pigment  as  is  fre- 
quently the  case  in  metastatic  melanoma.  A few  scattered  pig- 
mented cells  can  he  seen. 


Microscopically,  the  tumor  involved  the  bladder  wall 
and  infiltration  of  the  muscularis  was  noted  (see  figure 
2).  The  cells  were  large,  with  bizarre  basophilic  nuclei. 
Their  cytoplasm  contained  varying  quantities  of  melanin 
pigment.  Many  macrophages  were  noted,  and  acute 
inflammatory  cells  infiltrated  the  entire  area.  There  was 
consiflerable  necrosis  of  the  tumor  (see  figure  .S)  with 
fibroblastic  proliferation  and  scar  tissue  formation.  The 
blailder  mucosa  was  generally  intact  but  in  some  in- 
stances was  considerably  eroded.  'I'he  histologic  diagnosis 
was  melanocarcinoma  of  the  bladder,  metastatic  from 
the  thyroid  gland. 

The  patient  was  discharged  from  the  hospital  free  of 
symptoms  on  the  third  postoperative  day.  She  gradually 


lost  weight,  and  her  appetite  became  poor.  Three  weeks 
later  painful  swelling  developed  in  both  legs,  which  be- 
came progressively  worse.  Difficulty  in  swallowing  de- 
veloped, and  only  liquids  could  be  tolerated.  .\t  no  time 
did  she  show  any  signs  or  symptoms  referable  to  the  eyes. 
Death  occurred  on  July  4,  1949,  13  months  after  the 
appearance  of  the  neck  tumor. 

The  diagnosis  was  metastatic  melanoma  to  the  bladder 
with  the  possibility  of  its  being  primary  in  the  thyroid 
gland.  This  diagnosis  was  concurred  in  by  Colonel  J. 
E.  Ash. 


Fig.  2.  Section  through  thyroid  tumor  in  area  of  cajisule, 
showing  a thick  fibrous  connective  tissue  membrane  containing 
a few  thyroid  acini  lined  by  a low  cuboidal  e|)ithelium;  diffuse 
infiltration  by  small  lymjjhocytes.  Within  the  tumor  itself  the 
cells  are  variable  in  size  and  occluded  by  heavy  concentration 
of  melanin  jiigment  which  can  he  seen  in  small  granules  and 
heavy  globules.  Small  thyroid  acini  can  also  be  seen  within  the 
tumor  itself. 


Discussion 

I'his  uni(|ue  case  follows  a relatively  typical 
jiattern  of  a malignant  melanoma.  If  the  onset 
is  thought  to  he  at  the  time  of  finding  the  en- 
larged mass  in  the  thyroid,  there  was  a (juiescent 
period  of  8 months  during  which  metastasis  de- 
velofted,  finally  with  demonstrable  evidence  of 
metastasis  to  the  bladtler,  the  regional  pelvis, 


86 


Metastatic  Melanoma  to  Bladder^Stlrling  and  Hunter 


FEBRUARY,  1952 


and  the  lymph  nodes  of  the  abdomen.  The 
thoracic  lymph  nodes  were  also  affected  and 
produced  obstruction  of  the  return  of  venous 
lymph  terminally.  The  tumor  was  apparently 
])rimary  in  the  thyroid  gland.  Proof  is  largely 
presumptive,  but  the  evidence  strongly  supports 
the  thyroid  origin. 


Fig.  3.  Section  through  a lymph  node  adjacent  to  tumor, 
showing  a typical  secondary  follicle  with  large  metastatic 
tumor  cells  containing  melanin  jiigment  in  the  cortex  and  in 
the  peripheral  sinus.  This  is  apiiarently  an  early  evidence  of 
metastasis  from  the  thyroid  tumor 

Incor{)oration  of  the  tumor  within  thyroid 
tissue  with  a capsule  of  thyroid  gland  and  a 
mingling  of  thyroid  acini  within  the  tumor  it- 
self strongly  favor  that  site  as  the  origin  of  the 
tumor.  The  size  of  the  original  mass  further  adds 
weight  to  this  hypothesis,  and  finally  the  absence 
of  symptoms  referable  to  the  usual  sites  of  pri- 
mary melanocarcinoma  favors  the  thyroid  gland 
as  the  primary  origin. 

In  discussing  primary  melanocarcinoma  of  the 
thyroid  gland,  a review  of  the  pertinent  litera- 
ture indicates  two  possibilities.  Chlmour,'  Erd- 


heim,-  and  Habcrfeld'*  described  in  a number  of 
instances  cells  of  the  parathyroid  gland  which 
contained  pigment  which  is  “not  iron  but  has  a 
brownish  color.”  This  pigment  was  contained 
within  fibroblast-like  cells  of  the  parathyroid 
glands,  and  it  has  been  suggested  by  all  3 authors 
to  be  melanin  or  a melanin-like  pigment.  Fur- 
ther, FraenkeP  and  Kreglinger^  reported  2 pri- 
mary melanocarcinomas  of  the  parathyroid 
gland.  These  2 authors  were  of  the  opinion  that 
the  neoplasms  were  primarily  tumors  within  the 
parathyroid  gland.  In  the  case  reported  by  Kreg- 
linger  there  were  unpigmented  metastases  in 
other  areas  of  the  body.  Both  cases  had  primary 
pigmented  lesions.  Superficial  consideration  of 
the  relationship  of  melanin-producing  cells  and 
thyro.xin-producing  cells  of  the  thyroid  gland 
would  seem  to  be  antipodal.  However,  when  it 
was  considered  that  both  melanin  and  thyroxin 
have  a common  origin  it  becomes  less  difficult 
to  postulate  the  possibility  of  thyroid  tissue  pro- 
ducing a melanin  tumor.  Melanin  tumors  usually 
oxidize  either  tyrosine  or  phenylalanine  to  the 
pigment.  Tyrosine  likewise  by  a process  of  iodini- 
zation  may  form  thyro.xin  by  union  with  a para- 
hydroxy])henyl  group.  This  produces  a para- 
hydroxyphenyl  ether  of  tyrosine  which  has  the 
iodine  in  the  3,5,  and  3',  5'  positions.  There  is, 
then,  a similarity  between  the  2 materials.  The 
close  chemical  relationship  is  further  supported 
by  recent  evidence  uncovered  through  work  on 
synthetic  sweetening  agents.  Fitzhugh  and  Xel- 
soiT  found  a melanin  pigment  in  rat  thyroids 
after  feeding  of  1 -n-propo.xy-2-amino-4-nitro- 
benzene,  a synthetic  sweetening  agent.  This  pig- 
ment had  all  of  the  chemical  reactions  of  melanin 
and  was  found  in  the  thyroid  epithelium  and  in 
the  lumen.  The  a])parent  unusual  relationship  of 
the  thyroid  gland  and  the  melanin  tumor  there- 
fore is  not  so  odd. 

I’he  following  diagram  shows  the  close  rela- 
tionship of  melanin  with  thyroxin  in  its  initial 
development  and  suggests  the  method  by  which 
a thyroid  tumor  could  develop  melanin  pigment. 


VOL.  XXI,  NO.  2 


Medical  Annals  of  the  District  of  Columbia 


87 


NH. 

CHo-CH-COOH 


NH.. 

.1 

CH.-CH-COOH 


OH 


Phenylalanine 


NH, 


Tyrosine 

/ \ 

NH, 


CH,-CH-COOH  CHa-CH-COOH 


3 , 4-Dioxyphenyl 
alanine 

i 

Melanin 


Diiodotyrosine 

i _ 

Thyroxine 


Summary 

case  is  described  of  an  apparently  primary 
melanocarcinoma  of  the  thyroid  gland  which 
later  developed  a metastatic  melanotic  tumor 


in  the  bladder.  References  in  the  literature  have 
been  found  of  primary  melanocarcinomas  in  the 
parathyroid  glands,  but  no  evidence  of  any  pre- 
vious melanocarcinoma  of  the  thyroid  gland  has 
been  noted.  Chemically  speaking,  there  is  a close 
relationship  between  thyroxin -producing  cells 
and  melanin  which  may  explain  a possible  re- 
lationship. 


BIBLIOGRAPHY 

1.  Gilmour,  J.  R.:  Normal  histology  of  parathyroid  glands. 

J.  Path.  & Bact.,  1939,  48,  187. 

2.  Erdheim,  j.;  Ueber  Epilhelkbrperbefunde  bei  Osteomalacie. 

Sitzungsb.  d.  Akad.  d.  Wissensch.  Mathemat.-naturvv. 
KL,  Wien.,  1907,  116,  3.  .\bt.,  311. 

3.  Haberfeld,  W.:  Die  Epithelkorperchen  bei  Tetanic  und 

bei  einigen  anderen  Erkrankungen.  Virchows  Arch.  f. 
path.  Anat.,  1911,  203,  282. 

4.  Fr.aenkel,  F.  : Ueber  einen  Fall  von  priniaerem  Melanosar- 

koni  der  Schilddruese.  Prag.  med.  Wchnschr.,  1897,  22, 
321. 

5.  Kreglinger,  R.;  Primaere  Sarkome  der  Schilddruese  mit 

seltenen  Metastasen.  Arch.  f.  klin.  Chir.,  Berk,  1918, 

111,  545. 

6.  Fitzhugh,  O.  G.,  and  Nelson,  A.  A.:  Abstract  concerning 

chronic  toxicity  of  4 synthetic  sweetening  agents.  Fed- 
eration Proc.,  1950,  9,  272. 


I 


I 


SOCIETY  AND  THE  PHYSICIAN 
VIII.  The  Physician  and  the  Community 


When  I look  around  and  see  what  an  increasingly  important  part  physicians  are  playing 
in  nonmedical  community  activities,  I am  quite  i)leased.  This  is  following  in  the  footsteps 
of  the  family  physician  who  was  a “pillar”  of  his  community — a healer,  a confessor,  and  a 
solid  citizen. 

I can  point  with  pride  to  one  of  our  members  who  now  is  President  of  the  Federation  of 
Citizens’  Associations.  Another  has  distinguished  himself  on  the  Board  of  Education.  Another 
spent  endless  hours  on  the  annual  Community  Chest  Fund  Drive  with  the  help  of  a number 
of  his  fellow  physicians.  Several  physicians  are  active  in  their  Parent-Teachers’  Association 
work.  Others  are  on  the  boards  of  various  schools,  the  Boys’  Club,  the  Boy  Scouts,  and  many 
other  character-building,  religious,  and  welfare  organizations. 

It  would  be  interesting  to  name  all  of  these  people  by  name,  but  hardly  politic.  Neverthe- 
less, I ]K)int  with  pride  to  these  men  who  are  doing  an  e.xcellent  job  of  being  good 
citizens  in  our  community.  I hope  that  the  i)hysicians  of  Metropolitan  Washington  never 
become  “specialists”  in  the  sense  that  they  “know  more  and  more  about  less  and  less,”  but 
rather  that  their  interests  and  activities  may  continue  to  broaden  both  in  medical  and  non- 
medical fields. 

The  influence  of  the  American  physician  need  not  be  felt  in  the  field  of  health  alone  but 
rather  in  every  reasonable  field  of  activity.  Our  influence  is  as  broad  as  our  horizon. 


OF 

THE  MEDICAL  SOCIETY  OF  THE  DISTRICT  OF  COLUMBIA 

February  20  and  21,  1952 

MEDICAL  SOCIETY  BUILDING  1718  M Street,  N.W. 


MODERN  THERAPY:  ACCEPTED  METHODS  AND  EUTURE  POSSIBILITIES 

WEDNESDAY,  FEBRUARY  20— AFTERNOON  SESSION 

Darrell  C.  Crain,  M.D.,  Presiding 


2:00  Cancer 

Calvin  T.  Klopp,  M.D. 

Director,  George  Washington  University- 
Cancer  Clinic;  Assistant  Clinical  Profes- 
sor of  Surgery,  George  Washington  Uni- 
versity School  of  Medicine 

2:30  Intractable  Pain 

Donald  Stubbs,  M.D. 

Clinical  Professor  of  Anesthesiology, 
George  Washington  University  School  of 
Medicine 

3:00  Tuberculosis 

Sol  Katz,  M.D. 

Adjunct  Clinical  Professor  of  Medicine, 


Georgetown  University  and  George  Wash- 
ington University  Schools  of  Medicine 
3:30  Intermission 
3:45  Cardiac  Arrhythmias 

William  L.  HoweU,  M.D. 

Assistant  Clinical  Professor  of  Medicine, 
Georgetown  University  School  of  Medi- 
cine 

4:15  Toxemias  of  Pregnancy 

Frank  A.  Finnerty,  Jr.,  M.D. 

Chief  Resident  in  Medicine,  Georgetown 
Division,  Gallinger  Municipal  Hospital 
4:45  Threatened  Abortion 

Richard  H.  Fischer,  M.D. 

Research  Foundation,  Doctors  Hospital 


WEDNESDAY,  FEBRUARY  20— EVENING  SESSION 

Edward  B.  Tuohy,  M.D.,  Presiding 


8:00  Introductory  Remarks 

Frank  D.  Costenbader,  M.D. 

President,  The  Medical  Society  of  the 
District  of  Columbia 

8:05  The  Davidson  Lecture:  The  Amygdaloid 
Nucleus — A Clinical  Study  of  Its  Bilateral 
Ablation  and  a Theory  as  to  Its  Function 
Jonathan  M.  Williams,  M.D. 

Associate  in  Neurosurgery,  George  Wash- 
ington University  School  of  Medicine 
8:40  Panel  Discussion  on  Modern  Therapy  of 
Psychiatric  States 
Winfred  Overholser,  M.D.,  Moderator 
Superintendent,  Saint  Elizabeths  Hospi- 
tal 


Discussants 

Stanley  H.  Eldred,  M.D. 

Chestnut  Lodge,  Rockville,  Md. 

Zigmond  M.  Lebensohn,  M.D. 
Associate  Professor  of  Psychiatry,  Georgetown 
University  School  of  Medicine 

Isadora  Rodis,  M.D. 

Associate  Professor  of  Psychiatry,  Georgetown 
University  School  of  Medicine 

James  W.  Watts,  M.D. 

Professor  of  Neurological  Surgery,  George 
Washington  University  School  of 
Medicine 


89 


MODERN  THERAPY:  ACCEPTED  METHODS  AND  FUTURE  POSSIBILITIES 
THURSDAY,  FEBRUARY  21— AFTERNOON  SESSION 
Oscar  B.  Hunter,  Jr.,  M.D.,  Presiding 


2:00  Use  of  Whole  Blood 

Brig,  Gen.  Sam  F.  Seeley,  MC,  USA 
Walter  Reed  Army  Hospital 
2:30  Parexteral  Fluids  Other  than  Whole 
Blood 

Jacob  J.  Weinstein,  M.D. 

Associate  in  Surgery,  George  Washington 
University  School  of  Medicine;  Associate 
in  Surgery,  Gallinger  Municipal  Hospital 
3:00  Gastrointestinal  Bleeding 
Hugh  H.  Hussey,  M.D. 

Associate  Professor  of  Medicine,  George- 
town L’niversity  School  of  Medicine; 
Editor  of  G.  P. 

and 

Paul  Kiernan,  M.D. 

.Associate  Professor  of  Surgery,  George- 
town University  School  of  Medicine 
3:30  AxEfflAS 

Jack  J.  Rheingold,  M.D. 

Clinical  Instructor  in  Medicine,  George 
Washington  University  School  of  Medi- 
cine 

4:00  Intermission 

4:15  Panel  Discussion  on  the  Use  and  Abuse 
OF  Some  New  Drugs 

Wallace  M.  Yater,  M.D.,  Moderator 

Director,  Yater  Clinic;  formerly  Professor 
of  Medicine,  Georgetown  University 
School  of  Medicine 

Discussants 

“Cardiology” 

Joseph  M.  Barker,  M.D. 
Cardiologist,  Yater  Clinic 


Assistant  Clinical  Professor  of  Medicine, 
Georgetown  University  School  of  Medicine 

“Neurology” 

Francis  M.  Forster,  M.D. 

Professor  and  Director  of  the  Department  of 
Neurology,  Georgetown  University 
School  of  Medicine 

“Endocrinology” 

Laurence  H.  Kyle,  M.D. 

Assistant  Professor  of  Medicine,  Georgetown 
University  School  of  Medicine 

“Pulmonary  Diseases” 

John  W.  Trenis,  M.D. 

Associate  in  Medicine,  George  Washington 
University  School  of  Medicine 

“Gastroenterology” 

John  C.  Sullivan,  M.D. 

Assistant  Clinical  Professor  of  Medicine, 
Georgetown  University  School  of 
Medicine 

“.Antibiotics” 

Lt.  Col.  Edwin  J.  Pulaski,  MC,  USA 
Walter  Reed  .Army  Hospital 

“Allergy” 

Eloise  W.  KaUin,  M.D. 

Associate  Editor  of  .Allergy  .Abstracts,  Journal 
of  Allergy 


THURSDAY,  FEBRUARY  21— EVENING  SESSION 

8:15  Special  Business  Meeting 

8:45  Joint  Meeting  of  the  Medical  Society  of  the  District  of  Columbia  and  the  Woivlan’s 
.Auxili.ary 

Speaker;  James  T.  Berryman 
Cartoonist,  The  Evening  and  Sunday  Star,  Washington,  D.C. 

Social  Hour  and  Refreshments  in  the  Library  Will  Follow 

90 


THE  HOSPITAL  STAFF  MEETING 


Largely  through  the  unremitting  efforts  of 
the  American  College  of  Surgeons,  the  standard 
of  hospitalization  has  been  raised  to  a very  high 
plane,  and  much  credit  is  due  the  respective 
Boards  of  Directors  and  the  Medical  Staffs  for 
their  earnest  cooperation.  There  were,  of  course, 
many  problems  to  be  considered,  one  of  which, 
and  not  the  least,  was  the  Staff  Meeting. 

Before  the  College  engaged  in  this  reorganiza- 
tion, hospital  staff  meetings  were  held  at  irregular 
periods,  and  the  subjects  for  consideration  were 
prepared  with  little  relation  to  medical  care  and 
institutional  efficiency.  The  staff  meeting  now 
occupies  an  important  place  in  the  management 
of  the  hospital,  both  from  the  medical  and  ad- 
ministrative standpoint.  The  College  stipulated 
that  meetings  should  be  held  monthly  and  with 
an  attendance  of  at  least  75  per  cent  of  the  staff. 
Few  hospitals  have  measured  up  to  this  require- 
ment, although  most  are  making  a diligent  effort 
to  do  so  To  keep  up  the  attendance,  various 
schemes  have  been  adopted,  such  as  fines,  voiding 
privileges,  and  failure  of  reappointment  to  the 
staff,  and,  on  the  reverse,  furnishing  luncheon 
for  those  in  attendance. 

The  absenteeism  is  probably  not  due  to  loss  of 
interest  but  can  be  laid  at  the  door  of  professional 
duties  and  membership  on  the  staffs  of  several 
hospitals.  If  staff  members  would  limit  their 
affiliations  to  one  or  two  hospitals,  instead  of 
three  or  more,  it  would  afford  them  more  time 
for  staff  meetings  and  also  create  vacancies  on 
the  staffs  of  other  hospitals  which  could  be  filled 
by  qualified  doctors,  of  whom  there  are  many. 

'Fhe  subjects  discussed  at  the  meetings  are 
often  at  great  variance  with  the  intent  and  direc- 


tion of  the  College.  The  primary  and  almost  sole 
purpose  is  to  review  and  analyze  the  work  of  the 
institution  with  the  view  of  improving  the  calibre 
of  its  product.  It  should  not  be  content  to 
enumerate  the  deaths  for  the  preceding  month, 
but  should  demand  a full  explanation  of  any 
unusual  circumstance  associated  with  the  death, 
treatment,  or  management  of  any  patient.  In- 
fections and  reactions  should  be  tabulated  and 
measures  adopted  to  keep  them  within  the 
accepted  rate  of  occurrence.  There  are  a number 
of  other  items  which  could  be  presented,  such  as 
injuries  and  accidents  to  patients,  complaints 
relating  to  their  professional  care,  intern  rela- 
tions, and  so  on.  The  use  of  newer  drugs,  the 
application  of  advanced  principles  in  surgery, 
and  collateral  specialties  are  also  subjects  of 
general  interest  but  should  not  be  the  major 
topic  of  the  meeting.  Boiled  down  to  a few 
words,  the  object  of  a staff  meeting  is  to  promote 
all  measures  that  afford  each  patient  the  maxi- 
mum chance  of  recovery  by  a review  and  anal- 
ysis of  the  professional  activities. 

The  administrator  of  the  hospital  should  be 
present  at  staff  conferences  as  there  are  many 
problems  that  invade  and  overlap  the  pro- 
fessional and  administrative  departments;  there 
is  no  better  place  to  discuss  them  than  in  a staff 
meeting. 

'Fhe  staff  meeting  does  not  by  any  stretch  of 
the  imagination  replace  the  meeting  of  the  local 
medical  society  or  any  of  its  affiliates  or  any 
indei)endent  association  of  medical  men.  When  a 
hosi)ital  sends  a notice  that  the  next  meeting 
will  consist  of  a discussion  of  “interesting  cases,” 


Opinions  expressed  in  contributions  to  the  Editorial  Section  are  those  of  the  writers  and 
do  not  necessarily  reflect  the  views  of  The  Medical  Society  of  the  District  of  Columbia 

91 


92 


Editorials 


FEBRUARY,  1952 


it  is  certainly  not  conversant  with  the  aims  or 
directives  of  the  College  of  Surgeons. 

It  may  require  some  patience  and  determina- 
tion on  the  part  of  the  governing  bodies  to  dis- 
card or  revamp  the  old  order,  but  if  a hospital 


e.\pects  to  maintain  a high  state  of  efficiency  and 
receive  accreditation  as  an  approved  institution, 
it  can  do  so  by  putting  its  house  in  order.  It  can 
be  done. 

C.S.W. 


WOMEN  PHYSICIANS  OF  WASHINGTON 


The  November  1951  issue  of  the  Journal  of 
the  American  Medical  Women's  Association  is  of 
especial  interest  to  all  physicians  of  the  Washing- 
ton area.  The  Women’s  Medical  Society  of  the 
District  of  Columbia,  Branch  One  of  the 
National  Group,  has  provided  the  material  for 
the  November  number.  I r.  Elizabeth  Kittredge 
was  chairman  of  the  special  committee  appointed 
for  this  purpose. 

'I'he  issue  is  a very  creditable  one  in  all  re- 
spects. 'rhe  scientific  papers  were  all  prepared 
by  women  physicians  of  Washington.  They 
include  an  article  based  on  animal  e.xperiments 
in  leukemia  by  Dr.  Thelma  Dunn;  a study  of  the 
effect  of  anxiety  on  the  electrocardiogram  by  Dr. 
Ruth  Benedict;  an  extensive  review  article  on 
allergy  by  Dr.  Eloise  Kailin;  and  two  interesting 
case  reports,  one  by  Dr.  Josephine  Renshaw  and 
the  other  by  Dr.  Margaret  Callen.  Dr.  Alice 
Brigham  described  the  operation  of  a home  serv- 
ice for  cancer  patients.  Mrs.  Irene  Kennedy, 
woman  lawyer  of  Washington,  e.xplains  the  need 
for  a new  District  law  to  provide  ecjuitable  distri- 
bution of  estates  in  instances  of  simultaneous 
death. 

Dr.  Kittredge  has  contributed  a fascinating 
account,  “The  History  of  Branch  One  of  the 
.\merican  Medical  Women’s  Association.”  The 
Branch  had  its  beginnings  in  1909  with  15  women 
physicians  present.  Meetings  have  been  held 
monthly  almostwithout  exception  from  1909  until 
the  present,  usually  in  the  homes  of  members. 
The  purpose  of  the  organization  from  its  begin- 
ning has  been  scientific.  The  topic  of  the  paper 
for  October  1909  was  “A  Slight  Review  of  Ortho- 
pedics” by  Dr.  Emma  Erving,  who  is  said  to  be 
the  only  woman  orthopedist  in  the  history  of 


Branch  One.  Although  the  scientific  aspect  has 
predominated,  the  members  have  from  time  to 
time  interested  themselves  in  other  things,  such 
as  woman  suffrage,  food  conservation,  white 
slave  traffic,  proper  books  for  children,  and 
chastity  belts!  Through  the  years  the  ladies  have 
urged  equal  privileges  for  women  in  medical 
education  and  in  hospitals,  and  today  this 
equality  is  generally  accepted. 

Dr.  Lois  Platt  has  compiled  some  interesting 
statistics  regarding  “Women  Doctors  in  Wash- 
ington Today.”  She  estimates  that  there  are 
between  250  and  275  women  physicians  in  the 
Metropolitan  Area.  As  a result  of  a questionnaire 
distributed  to  them,  with  replies  from  189,  we 
learn  that  there  are  at  least  172  white  women 
physicians,  13  Negro,  and  4 others  in  the  Wash- 
ington area.  Sixty-three  of  these  are  under  35 
years  of  age,  107  are  35  to  60,  and  19  are  over  60. 
Of  the  total  number,  157  are  in  active,  full-time 
medical  practice,  and  18  practice  part-time.  Only 
three  of  the  entire  group,  in  Dr.  Platt’s  opinion, 
have  not  used  their  medical  education  ade- 
quately, and  two  of  these  did  “active  medical 
work”  for  five  or  more  years.  Eifty  of  the  group 
have  passed  the  specialty  boards  in  their  chosen 
fields;  of  these  14  are  in  psychiatry,  12  in  pedi- 
atrics, 6 in  pathology,  and  the  remainder  are 
broadly  scattered,  except  that  the  surgical 
specialties  are  scantily  represented.  Twenty-two 
are  employed  by  the  District  Health  Depart- 
ment. One  hundred  and  thirteen  are  married,  in 
51  instances  to  physicians;  7 are  divorced;  24 
under  the  age  of  35  are  single.  Ninety-one  have 
children,  the  total  number  of  children  being  181. 

.Mso  of  interest  are  the  data  given  on  the  status 
of  women  in  the  local  medical  colleges.  The  first 


VOL.  XXI,  NO.  2 


Medical  Annals  of  the  District  of  Columbia 


93 


woman  physician  graduated  in  the  District  in 
1872,  from  Howard  University;  George  Washing- 
ton University  graduated  its  first  woman  doctor 
of  medicine  in  1887,  and  Georgetown  University 
gave  its  first  M.D.  degree  to  a woman  in  1949. 
Currently  (1950^51)  10  per  cent  of  Howard’s 
medical  students  are  women,  as  compared  to 
6.9  per  cent  at  Georgetown  and  4.8  per  cent  at 
George  Washington. 

It  is  interesting  to  note  that  three  members  of 
the  Washington  Branch  have  served  as  presi- 
dents of  the  American  Medical  Women’s  Associ- 


ation: Dr.  Louise  Tayler-Jones,  Dr.  Kate 
Karpeles,  and  Dr.  Mary  O’Malley. 

In  the  section  entitled  “Album  of  Women  in 
Medicine,”  there  are  biographical  sketches  of 
Dr.  Frances  Foye  and  Dr.  May  Davis  Baker, 
two  of  the  women  who  have  been  most  influential 
in  the  history  of  the  local  liranch. 

Dr.  Kittredge  deserves  real  credit  for  the  e.x- 
cellence  of  the  November  number  of  the  Journal, 
the  monthly  publication  which  has  replaced  the 
quarterly  Women  in  Medicine  of  which  she  was 
formerly  the  editor. 

Thomas  M.  Peery-,  M.D. 


FLUORIDATION  OF  COMMUNITY  WATER  SUPPLY 


One  of  the  most  prevalent  diseases  yet  to  lie 
controlled  is  dental  caries,  which  affects  almost 
the  entire  population.  Although  dentistry  has 
made  phenomenal  progress  in  the  development  of 
newer  technics  and  procedures  for  better  dental 
health,  until  recently  it  did  not  have  the  benefit 
of  specific  control  measures.  The  findings  of  the 
Selective  Service  in  World  Wars  1 and  1 1 clearly 
indicated  that  the  dentists  were  faced  with  a 
problem  which  required  drastic  control  measures. 
The  annual  increment  of  untreated  dental  caries 
has  resulted  in  increased  tooth  mortality.  The 
child  population  receives  only  about  one  third  of 
the  fillings  required  and  the  remaining  two  thirds 
are  neglected.  Sixteen-year-olds  have  an  average 
of  9 decayed  teeth  with  a loss  of  several  others. 

The  acceptance  of  the  caries  fluorine  hy- 
potheses is  the  result  of  exhaustive  epidemio- 
logic studies  and  constitutes  a milestone  in  public 
health  and  preventive  dentistry.  Historically,  the 
possible  relationship  of  fluorides  and  dental  caries 
was  postulated  by  Sir  Chrichton-Brown  of  Eng- 
land just  before  the  turn  of  the  century. 
similar  observation  was  made  by  a U.  S.  Public 
Health  Officer  attached  to  the  United  States 
Consulate  in  Na{)les,  Italy,  in  1901.  Dr. 
Frederick  McKay,  a New  \’ork  dentist  who  spent 
his  summers  in  Colorado,  called  attention  to  the 
extensive  mottled  teeth  in  that  area  and  sug- 


gested that  there  might  be  something  in  the 
water  responsible  for  this  defect.  The  early  obser- 
vations of  Dr.  McKay  (1908-1915)  undoubtedly 
were  the  forerunner  of  the  extensive  research 
that  followed.  Fluorine  as  an  element  was  first 
observed  in  water  in  1931  by  an  industrial 
chemist. 

Since  that  time  epidemiologic  studies  were 
conducted  in  widely  separated  parts  of  the 
United  States.  It  was  conclusively  proved  that 
the  use  of  fluoridated  drinking  water  during  the 
formative  period  of  the  teeth  is  associated  with 
a 60  to  65  per  cent  reduction  in  dental  caries 
e.xperience.  The  results  of  these  studies  indicated 
that  not  only  was  1.0  ppm.  in  the  drinking  water 
an  optimum  concentration  for  caries  control  but 
well  within  the  limits  of  safety.  All  investigations 
revealed  that  there  were  no  toxic  evidences  of 
fluorosis  within  safe  limits.  Further,  it  was  ob- 
served that  a concentration  of  1.0  ppm.  of 
fluoride  in  public  drinking  water  supplies  effected 
maximum  protection  against  dental  decay.  In 
1945,  studies  to  determine  the  caries  prophylactic 
value  of  artificially  fluoridated  drinking  water 
were  started  in  Grand  Rapids,  Michigan  and  in 
Newburg,  New  \'ork.  Numerous  additional 
study  j)rojects  have  been  initiated  in  the  United 
States  since  then.  .All  of  these  studies  have  pro- 
duced positive  and  comparable  results. 


94 


Editorials 


FEBRUARY,  1952 


'Fhe  ])rocedure  of  water  lluoriclation  in  the 
control  of  dental  caries  has  received  widespread 
approval  of  professional  and  scientific  groups. 
'Fhe  American  Medical  Association,  the  Ameri- 
can Dental  Association,  the  American  Public 
Health  Association,  the  State  and  Territorial 
Health  Officers,  the  Conference  of  State  Dental 
Directors,  the  United  States  Public  Health  Serv- 
ice, and  the  National  Research  Council  have  all 
endorsed  and  approved  this  procedure. 

Between  three  and  four  million  people  in  the 
United  States  have  been  drinking  water  con- 
taining fluorides  all  of  their  lives  and  have  suf- 
fered no  ill  effects  e.xcept  dental  fluorosis  in 
those  areas  having  high  concentrations  of  fluo- 
rides in  the  water.  At  the  concentrations  recom- 
mended for  fluoridated  water  supplies,  there  is  no 
discoloration  of  the  teeth.  In  fact,  people  who 
have  consumed  water  containing  the  recom- 
mended amount  of  fluoride  have  unusually 
attractive  teeth. 

Fluorides  are  comj)ounds  formed  by  fluorine 
combining  with  other  elements.  These  com- 
pounds include  sodium  fluoride,  calcium  fluoride, 
potassium  fluoride,  magnesium  fluoride,  and 
others.  Other  combinations  form  silicofluorides. 
Fluoride  does  not  add  taste,  color,  odor,  or  hard- 
ness to  water.  Flven  at  higher  concentrations,  the 
use  of  fluoride-bearing  water  has  had  no  known 
effects  in  industrial  processes.  Chlorination  does 
not  interfere  with  the  beneficial  effects  of  fluori- 
dation. 

The  exact  mechanism  by  which  fluorine  com- 
pounds jrrovide  protection  against  dental  caries 
is  not  definitely  established.  Research  on  this 
problem  has  suggested  three  hypotheses: 

1 . Fluoride  lowers  the  solubility  of  tooth  struc- 
ture. 

2.  Fluoride  inhibits  the  bacterial  or  enzymatic 


processes  that  are  believed  to  dissolve  the  protein 
and  calcified  substance  of  the  tooth. 

3.  Fluoride  changes  the  bacterial  flora  of  the 
mouth,  thereby  reducing  the  number  of  acido- 
genic  bacteria  that  are  associated  with  the  caries 
process. 

It  is  possible  that  any  one  or  a combination  of 
these  actions  results  in  a greater  resistance  to 
caries. 

To  summarize  the  whole  procedure,  it  can  be 
said  that: 

Fluoridation  of  community  water  supplies 
represents  a significant  advance  in  public  health 
practice.  By  the  relatively  simple  procedure  of 
controlling  the  fluorine  concentration  of  potable 
water  it  is  possible  to  reduce  dental  caries  by  65 
per  cent  and  to  reduce  tooth  mortality  to  a 
reasonable  limit.  The  technic  involved  is  rela- 
tively simple  and  can  be  accomplished  at  a low 
cost.  Extensive  research  has  proven  the  pro- 
cedure to  be  safe  when  properly  administered 
and  that  it  will  provide  the  greatest  benefit  to 
children  from  birth  up  to  age  8 during  the  calci- 
fication period  of  the  teeth.  There  is  no  odor  or 
taste  to  the  water  and  industrial  procedures  are 
not  known  to  be  affected. 

The  Commissioners  of  the  District  of  Colum- 
bia have  approved  the  recommendation  of  the 
Director  of  Public  Health  to  fluoridate  the  local 
water  supply,  and  an  appropriation  of  Si 30,000 
was  secured  for  this  fiscal  year.  Equipment  has 
been  purchased  and  will  be  installed  in  the  Dale- 
carlia  Filter  Plant.  The  chemical  has  been 
purchased  and  it  is  anticipated  that  fluoridation 
for  the  F)istrict  of  Columbia  will  begin  on  or 
about  March  15,  1952. 

A.  Harry  Ostrow,  D.D.S. 
Director,  Bureau  of  Dental  Services, 
D.  C.  Health  Department 


VOL.  XXI,  NO.  2 


Medical  Annals  of  the  District  of  Columbia 

HEALTH  DEPARTMENT  HIGHLIGHTS,  1951 


95 


Constant  improvement  of  the  health  of  the 
residents  of  the  District  of  Columbia  is  the  prime 
objective  of  the  Health  Department’s  services. 
Because  of  variations  in  measuring  devices  and 
because  of  the  long-term  factors  involved, 
achievements  in  public  health  are  not  always 
evident.  It  is  only  during  years  immediately 
following  decennial  census  enumeration  that  full 
dependence  may  be  placed  upon  population 
figures. 

Residents  of  the  District  enjoyed  a successful 
year  in  1951  from  a public  health  point  of  view — 
a year  in  which  the  citizens  of  this  city  may 
justly  take  pride.  The  provisional  general  death 
rate  (deaths  from  all  causes)  is  lower  in  1951 
than  it  was  in  1950.  Deaths  due  to  selected 
causes  generally  showed  a decrease.  Maternal 
mortality  rates  continued  to  decline  to  the  lowest 
rate  ever  recorded.  The  tuberculosis  death  rate 
shows  the  greatest  reduction  ever  occurring  in 
Washington  in  any  one  year.  Deaths  due  to  heart 
disease  and  cancer  show  a lower  rate  than  the 
year  1950.  Deaths  due  to  pneumonia  and  in- 
fluenza and  poliomyelitis  also  showed  a decline. 
More  births  were  recorded  in  the  District,  more 
than  one  third  of  which  were  to  mothers  residing 
outside  the  District  boundaries.  And  while  there 
were  more  cases  of  scarlet  fever,  whooping  cough 
and  chickenpox,  there  were  fewer  cases  of  pneu- 
monia, influenza,  poliomyelitis  and  measles  re- 
corded. 

Vital  Statistics 

With  a birth  to  a resident  mother  occurring 
every  26^  minutes  and  a death  to  a resident 
occurring  every  64  minutes,  there  was  a natural 
increase  of  11,556  persons  in  the  District  of 
Columbia  during  the  year  just  closing.  Daily 
there  were  54  births  and  22.4  deaths,  making  a 
total  of  1 9,773  births  and  8,2 1 7 deaths  to  District 
residents. 

The  resident  birth  rate  per  1,000  population, 
therefore,  is  estimated  to  be  24.0,  which  is  0.1 


below  the  1950  figure,  and  0.7  below  the  all-time 
high  rate  of  24.7  births  per  1,000  population  re- 
corded in  1947.  These  rates  refer  to  births  to  resi- 
dent mothers  only.  The  crude  birth  rate,  uncor- 
rected for  residence,  was  higher  than  in  any 
previous  year.  The  uncorrected  rate  per  1,000 
j)opulation,  that  is,  births  recorded  in  Washing- 
ton in  1951,  was  37.0.  Numerically  there  were 
30,524  births  recorded  here,  nearly  1,600  greater 
than  the  number  recorded  in  1950. 

The  provisional  death  rate  for  1951  for  resi- 
dents of  the  District  is  somewhat  higher  than 
the  mortality  recorded  in  1950,  10.0  as  compared 
to  9.6.  Numerically  there  were  7,679  deaths  re- 
corded in  1950  whereas  in  1951  there  were  8,217  * 
deaths  recorded  for  residents  only.  For  deaths 
occurring  in  the  District,  including  resident  and 
nonresidents,  a total  of  8,978  occurred  here  in 
1951,  while  in  1950  there  were  9,012  deaths 
recorded.  The  death  rate,  from  all  causes,  for 
1951  for  all  deaths  which  occurred  in  the  District 
is  estimated  to  be  10.9  per  1,000  population;  in 
1950  the  death  rate,  uncorrected  for  residence, 
was  11.2  per  1,000  population. 

The  infant  death  rate  for  1951  approached  the 
previous  low  record  of  1948.  In  this  past  year 
the  757  infant  deaths  gave  a rate  of  24.8  per 
1,000  live  births,  while  in  1948  the  infant  death 
rate  was  23.9  per  1,000  live  births.  There  was  a 
reduction  of  0.4  from  last  year’s  recorded  rate  of 
25.2  deaths  jier  1,000  live  births. 

Closely  related  to  infant  mortality  is  maternal 
mortality.  The  record  attained  in  1951  is  the 
lowest  ever  recorded  for  Washington.  This  is  the 
third  consecutive  year  that  the  same  claim  may 
be  made;  each  year  there  was  a 0.1  decline.  The 
maternal  rate  for  this  j)ast  year  was  provisionally 
set  at  0.3  per  1,000  live  births  with  only  10 
deaths  due  to  childbirth  or  its  complications. 
This  is  a 16|  per  cent  reduction  from  the  12 
deaths  recorded  from  this  cause  in  1950. 

h'rom  table  1,  showing  recorded  live  births, 
deaths  from  all  causes,  and  deaths  from  selected 


96 


Editorials 


FEBRUARY,  1952 


causes,  it  may  lie  noted  that  progress  has  been 
made  in  the  attack  against  many  diseases  in  the 
District  in  the  past  year. 

A sharply  significant  decline  was  noted  in  the 
death  rate  from  all  forms  of  tuberculosis  during 
the  jrast  year.  The  death  rate  dropped  from  48.4 
per  100, 000  population  to  36.4  in  the  year  just 
closing.  This  is  a reduction  of  24.8  per  cent,  and 


TABLE  1 

Vital  Statistics  for  the  District  of  Columbia,  1951  and  1950 


IQSI  ESTIMATED 

1950 

Number 

Rate 

Number 

Rate 

Deaths,  all  causes* 

8,978 

10.9 

9,012 

11.2 

Deaths,  all  causes*  (cor- 

rected  for  residence) 

8,217 

10.0 

7,679 

9.6 

Live  births* 

30,524 

37.0 

28,926 

36, 1 

Live  births*  (corrected  for 

residence) 

19,773 

24.0 

18,099 

24.1 

Infant  mortality t 

757 

24.8 

729 

25.2 

Maternal  mortalityj 

10 

0.3 

12 

0.4 

Deaths  from  specific  causes 

t 

Heart  disease 

2,997 

363.2 

3,253 

405.5 

Cancer,  neo[)lasms,  malig- 

«( 

nant 

1,471 

178.3 

1,431 

178.4 

.\ccidents 

384 

46.5 

432 

53.9 

Tuberculosis,  all  forms.  . . 

300 

36.4 

388 

48.4 

Pneumonia  and  influenza . 

199 

24.1 

223 

27.8 

Diabetes 

104 

12.6 

130 

16.2 

Svphilis 

62 

7.5 

84 

10.5 

Meningococcal  infections. . . 

9 

1.1 

18 

1.0 

Poliomyelitis 

4 

0.5 

17 

2.1 

Whooping  cough 

2 

0.2 

1 

0.1 

Source:  Bureau  of  Vital  Statistics,  I).  C.  HealtlyDepart- 


ment. 

* Per  1,000  i)opulation 
t Per  1,000  live  births 
t Per  100,000  [lopulation 

the  greatest  reduction  in  the  tuberculosis  death 
rate  ever  recorded  in  the  District  in  any  12- 
month  period.  It  is  the  greatest  rate  decline  re- 
corded in  the  major  causes  of  death  during  the 
year.  Early  provisional  reports  for  tuberculosis 
indicate  a decline  in  the  national  rate,  also.  This 
is  probably  one  of  the  long-term  factors  evi- 
denced in  the  over-all  improvement  of  health  in 
Washington.  The  reduction  in  the  tuberculosis 
death  rate  gives  hope  that  with  improved  medical 


and  surgical  technics,  greater  use  of  antimicro- 
bial agents,  and  increased  activity  in  case-finding 
projects,  supported  by  more  enlightened  public 
understanding  and  cooperation  with  medical  and 
health  agencies,  there  can  be  an  even  lower 
tuberculosis  death  rate  than  that  recorded  this 
year.  Tuberculosis  is  still  responsible  for  more 
deaths  than  are  any  of  the  other  communicable 
diseases.  However,  it  should  be  recognized  that 
the  ultimate  goal  is  prevention  of  the  disease 
rather  than  only  the  prevention  of  deaths.  Much 
effort  is  still  necessary  to  find  cases  early  since, 
as  in  all  diseases,  early  detection  means  early 
cure. 

Syphilis  deaths  were  fewer  in  the  past  year, 
reducing  the  death  rate  from  10.5  in  1950  to  a 
current  rate  of  7.4.  The  number  of  deaths  due  to 
syphilis  were  84  in  1950  and  62  in  1951. 

Acute  communicable  disease  deaths  present  a 
gratifying  picture  this  past  year.  There  were  no 
deaths  from  scarlet  fever,  diphtheria,  or  measles. 
Nor  were  there  any  deaths  in  1950  from  these 
diseases.  Meningococcal  infections  caused  9 
deaths  this  year.  Only  4 deaths  were  due  to 
poliomyelitis  this  past  year  while  there  were  17 
in  1950.  The  number  of  deaths  caused  by  pneu- 
monia and  inffuenza  were  less  this  year  than  last, 
199  to  223,  which  shows  a death  rate  reduction 
from  27.8  in  1950  to  24.1  (per  100,000  popula- 
tion) in  1951. 

Deaths  due  to  cancer  and  other  malignant 
neoplasms  show  a slight  rate  reduction,  from 
178.4  in  1950  to  178.3  in  1951,  in  spite  of  an 
increase  in  the  number  of  deaths  from  cancer. 
Cancer  continues  to  be  the  Number  Two  Killer 
in  Washington. 

Heart  disease  deaths  totaled  2,997  in  1951,  for 
a death  rate  of  363.2  per  100,000  population,  as 
compared  to  3,253  deaths  from  heart  disease  in 
1950,  with  a rate  of  405.5.  Heart  disease  con- 
tinues to  be  the  Number  One  Killer  again  this 
year. 

Until  considerably  more  jmogress  can  be  made 
in  the  attack  on  heart  disease  and  cancer,  which 
diseases  this  year  caused  49.8  per  cent  of  all 
deaths  in  Washington,  and  a major  share  of  the 


VOL.  XXI,  NO.  2 


Medical  Annals  of  the  District  of  Columbia 


97 


deaths  throughout  the  Nation,  the  general  death 
rate  in  the  District  of  Columbia  will  remain  at 
about  its  present  level — just  above  or  just  below 
10.0  deaths  per  1,000  population. 

Conclusion 

The  goal  of  the  Health  Department  of  the 
District  of  Columbia  is  the  prevention  of  illness, 
injury  and  premature  death  and  the  attainment 
of  optimum  health.  This  appeals  equally  to  the 
rich,  the  middle  class,  and  the  poor.  To  approach 
such  a high  goal  is  the  aim  of  those  charged  with 
the  responsibility  of  public  health  in  the  Nation’s 
Capital.  Many  disciplines,  among  them,  medi- 
cine, dentistry,  nursing,  engineering,  the  various 
laboratory  sciences,  statistics,  education  and  ad- 


ministration, must  wholeheartedly  cooperate  in 
this  task.  The  Health  Department  which  em- 
braces these  disciplines  can  remain  progressive 
only  when  alert  to  community  needs.  The 
achievements  referred  to  in  this  brief  discussion 
indicate  that  every  attempt  is  being  made  to 
discover  community  needs  and  to  meet  them 
within  our  sphere  of  activity.  With  the  whole- 
hearted support,  the  untiring  cooperation,  and 
the  concerted  action  of  professional  medical 
groups  and  of  the  people  of  the  Nation’s  Capital, 
the  Health  Department  can  continue  to  achieve 
gratifying  results  in  serving  this  community. 

J.  Edgar  Caswell 

Director,  Bureau  of  Public  Heallh  Education, 

D.  C.  Health  Department 


J.  apt  0^  cjociti 


BY  THE  OBSERVER 


Developments  which  led  to 
Another  First  the  discontinuance  of  the  Medi- 
cal Society’s  Wednesday  night 
meetings  and  the  inauguration  of  a two-day  mid- 
winter scientific  meeting  were  reviewed  in  this 
column  some  months  ago  (see  “Scientific  Pro- 
gram Revamped,”  September,  1951  Medical 
Annals).  In  a special  report  to  the  Society  on 
October  21,  1951,  the  E.xecutive  Board  elabo- 
rated further  on  this  change  emphasizing  its 
experimental  nature. 

In  line  with  the  Board’s  recommendation,  the 
first  Midwinter  Seminar  will  be  held  in  the 
Society’s  auditorium  on  Wednesday  and  Thurs- 
day, February  20  and  21,  1952.  While  the 
Seminar  will  not  be  as  ambitious  an  undertaking 
as  the  Annual  Scientific  Assembly,  it  may 
well  become  of  equal  im[)ortance  to  the  medical 
profession  in  Washington.  Basis  for  this  assertion 
is  the  fact  that  the  following  features  of  the 
coming  Seminar  will  undoubtedly  become  perma- 
nent. 


^ The  program  will  be  of  a practical  nature 
and  will  consist  largely  of  talks  on  new  and 
accepted  methods  of  therapy.  Those  attending 
the  Seminar  will  be  given  an  opportunity  to  take 
part  in  the  discussion.  Talks  are  limited  to  20 
minutes  and  will  be  followed  by  a 10-minute 
question  period. 

^ The  Seminar  will  be  an  all-local  event,  every 
physician  on  the  program  being  on  staffs  of  local 
hospitals  or  engaged  in  private  practice.  Those 
attending  will  therefore  be  in  a position  to  evalu- 
ate the  best  clinical  and  investigative  work  in  the 
District  of  Columbia. 

^ The  Seminar  will  close  with  a joint  meeting 
of  the  Society  and  the  Woman’s  Auxiliary  on 
Thursday  evening,  February  2 1 . James  T.  Berry- 
man, cartoonist  of  The  Evening  Star,  has  ac- 
cepted an  invitation  to  s[)eak.  His  talk  will  be 
followed  by  a social  hour  and  refreshments  in  the 
library. 

d'he  Seminar  program  will  be  found  on  pages 
S9-9().  An  examination  of  it  will  reveal  what  an 


98 


In  and  Out  of  Focus — Observer 


FEBRUARY,  1052 


excellent  job  has  been  done  by  the  Program 
Committee,  of  which  Dr.  Darrell  C.  Crain  is  the 
Acting  Chairman.  Serving  with  him  are  Drs. 
Seymour  Alpert,  William  S.  Anderson,  Irving 
lAldman,  Herbert  S.  Gates,  William  L.  Howell, 
Paul  Kiernan,  David  H.  Kushner,  Arthur  A. 
Morris,  Jr.,  William  R.  Stovall  and  Jacob  J. 
Weinstein.  Because  of  the  demands  made  upon 
his  time.  Dr.  Edward  B.  Tuohy,  Chairman  of 
the  Committee,  found  it  necessary  to  ask  ]i)r. 
Crain  to  carry  on  for  him. 

The  Committee  has  endeavored  to  develop  a 
program  of  ecjual  interest  to  the  specialist  and 
the  general  practitioner.  It  believes  that  it  has 
succeeded  and  that  the  attendance  at  the  Semi- 
nar will  more  than  justify  its  expectations.  Your 
Observer  shares  this  optimism  and  is  confident 
that  there  will  be  many  successful  Seminars  in 
the  future. 

★ 

The  AMA  lost  no  time  in  con- 
ThePresi-  demning  President  Truman’s 
dent’s  New  recently  created  Commission  on 
Commission  the  Health  Needs  of  the  Nation. 

President  John  W.  Cline  fired  a 
broadside  charging  the  President  with  playing 
politics  with  the  “medical  welfare”  of  the  Ameri- 
can people.  Dr.  Cline  said,  “This  is  a shocking 
attempt  to  give  White  House  sanction  to  the 
brazen  misuse  of  defense  emergency  funds  for  a 
program  of  political  propaganda,  designed  to 
influence  legislation  and  the  outcome  of  the  1952 
election.”  Dr.  Gunnar  Gundersen,  able  Chair- 
man of  the  AMA’s  Executive  Committee,  who, 
it  was  reported,  had  accepted  an  appointment  to 
the  Commission,  promptly  refused  to  serve.  He 
was  no  less  critical  of  the  President  because  he 
said  the  Commission  was  in  his  opinion  “an 
instrument  of  practical  politics.” 

'Phis  hostile  reaction  came  as  a surprise  to 
many  people,  including  a numlier  of  physicians, 
principally  because  a nationally  known  physician 
and  a loyal  friend  of  the  medical  profession.  Dr. 
Paul  B.  Magnuson,  former  Medical  Director  of 


the  Veterans  Administration,  had  been  appointed 
Chairman.  Some  thought  Dr.  Cline’s  statement 
intemperate  and  that  it  would  offend  Dr.  Mag- 
nuson, which  it  did. 

In  a public  statement  issued  concurrently  with 
the  Executive  Order  creating  the  Commission 
and  defining  its  duties,  the  President  said:  “The  i 
Commission  has  one  major  objective.  During  this 
crucial  period  in  our  country’s  history  it  will 
make  a critical  study  of  our  total  health  require- 
ments, both  immediate  and  long-term,  and  will  j 
recommend  courses  of  action  to  meet  these 
needs.” 

The  President  specifically  instructed  the  Com- 
mission to  investigate  and  submit  its  recom- 
mendations with  respect  to  the  following: 

1.  Present  and  prospective  supply  of  phy- 
sicians, dentists,  nurses  and  other  medical  people 
and  the  ability  of  schools  to  provide  what  is 
needed. 

2.  The  ability  of  local  public  health  units  to 
meet  the  demands  of  civil  defense  requirements. 

3.  Problems  created  by  the  shift  of  workers  to 
defense-production  areas  which  would  require 
relocation  of  medical  personnel. 

4.  How  existing  and  planned  me'dical  facilities 
meet  j;)resent  and  prospective  needs. 

5.  Present  research  activities  in  the  field  of 
health  and  the  research  program  needed. 

6.  The  effect  on  maintaining  health  standards 
of  actions  taken  to  meet  long-range  military, 
civil  defense  and  veterans’  requirements. 

7.  The  adequacy  of  private  and  public  programs 
designed  to  provide  ways  to  pay  for  medical  care.  \ 

8.  How  much  the  Government  should  con-  j 
tribute  to  local  governments  for  health  purposes.  ' 

The  President’s  announcement  had  hardly 
made  the  newspapers  when  the  AMA  responded. 
As  might  have  been  e.xpected  there  was  con- 
siderable editorial  comment.  Your  Observer  has 
selected  what  to  him  were  significant  portions  of 
editorials  which  appeared  in  The  Xew  York 
Times,  The  Evening  Star  (Washington),  and  The 
Washington  Post. 

On  December  30,  1951  The  Xew  York  Times 
editorialized : 


VOL.  XXI,  NO.  2 


Medical  Annals  of  the  District  of  Columbia 


99 


“President  Truman  has  taken  what  should  be  a for- 
ward step  toward  breaking  the  deadlock  that  has  existed 
on  constructiv'e  action  for  a positive  health  program.  . . . 

“The  ability,  stature  and  reputation  of  the  member- 
ship of  the  new  commission,  which  is  to  be  headed  by 
Dr.  Paul  B.  Magnuson,  insure  the  professional  knowledge 
and  maturity  of  judgment  that  will  be  needed  to  make 
workable  recommendations  for  solving  some  of  these 
problems.  It  is  a Commission  in  which  both  the  public 
and  the  health  profession  can  have  confidence. 

“The  task  which  Dr.  Magnuson  and  his  colleagues 
face  is  a difficult  one  which  has  too  frequently  in  the 
past  been  marked  with  emotionalism  rather  than  facts 
and  sound  judgment.  The  new  Commission  will  be 
rendering  a valuable  service  if  it  can  clear  away  the  con- 
fusion that  now  exists  and  give  us  a positive  program  on 
which  all  segments  of  our  Society  can  work  together.” 

The  Washington  Post  for  December  31,  1951 
observed : 

“In  the  long  and  bitter  dispute  between  the  advocates 
of  compulsory  national  health  insurance  and  the  Ameri- 
can Medical  .Association,  the  forgotten  man  has  been  the 
citizen  in  need  of  more  and  better  medical  care.  .As  one 
perceptiv'e  doctor  put  it,  ‘We  have  licked  Oscar  Ewing, 
but  not  the  problem.’  That  is  why  a rew  approach  is 
vital,  and  why  President  Truman’s  appointment  of  a 15- 
member  Commission  on  the  Health  Needs  of  the  Nation 
comes  as  a breath  of  fresh  air. 

“.Along  with  distinguished  members  of  the  medical 
profession  as  well  as  lay  citizens,  Mr.  Truman  has  named 
a man  of  great  stature  to  head  the  new  commission. 
Dr.  Paul  B.  Magnuson  was  already  an  outstanding 
orthopedic  surgeon  when  he  built  a brand-new  reputation 
in  the  Veterans  .Administration  for  providing  the  veteran 
with  the  best  medical  care  obtainable  anywhere.  It  was 
Dr.  Magnuson  who  enlisted  the  help  of  the  country’s 
leading  medical  schools  on  a cooperative  basis.  Not  only 
does  the  new  appointment  make  use  of  Dr.  Magnuson’s 
persuasion  and  talent,  but  it  also  helps  repair  the  slight 
done  him  in  his  summary  discharge  by  V'eterans  .Ad- 
ministrator Gray  a year  ago. 

“It  is  also  to  Mr.  Truman’s  credit  that  he  has  learned 
from  experience.  Too  infrequently  does  he  abandon  a 
dead  horse.  ATt  in  this  case  he  seems  to  have  seen 
clearly,  as  others  have,  that  the  Ewing  plan  for  national 
health  insurance  is  hopelessly  defunct.  The  elaborate 
efforts  of  the  .AM.A  to  defeat  this  plan  have  resulted  in 
nothing  better,  however,  and  that  fact  certainly  justifies 
a new  and  independent  approach.” 

On  January  2,  1952  The  Tvening  Star  in  an 


editorial  entitled  “For  a Healthier  .America’’ 
said : 

“.Although  the  doctor  chosen  to  represent  the  .AM.A 
has  declined  to  serve  because  of  a belief  that  Mr.  Truman 
has  acted  only  for  self-serving  political  reasons,  the 
Commission’s  membership  is  distinguished  enough  to 
indicate  that  it  should  do  a good  job  in  carrying  out  its 
directive  to  listen  to  the  advice  of  all  viewpoints,  make  a 
searching  and  objective  inquiry  into  the  facts,  anri  report 
formally  on  its  findings  within  the  next  12  months. 
Certainly,  the  chairman  of  the  group  deserves  the  con- 
fidence of  those  who  have  been  accusing  the  administra- 
tion of  wanting  to  enact  ‘socialized’  medicine.  He  is  Dr. 
Paul  B.  Magnuson,  former  Medical  Director  of  the 
Veterans  .Administration  and  a leading  opponent  of  the 
proposal  for  compulsory  health  insurance  or  anything 
else  smacking  of  the  British  system.  In  the  circumstances, 
it  is  difficult  to  understand  why  the  .AM.A’s  president 
has  branded  the  whole  study  project  as  ‘a  shocking  at- 
tempt’ to  play  politics.” 

Finally,  on  January  8,  1952,  The  Washington 
Post  published  an  editorial  w^arning  that: 

“The  danger  is,  if  the  opposition  of  the  .AM.A  to  any 
sort  of  change  persists,  that  the  country  some  day  may  be 
saddled  with  an  inferior  scheme  which  would  meet 
neither  the  objection  of  the  doctors  nor  the  real  needs 
of  the  public.  We  cannot  believe  that  the  sour  comment 
of  the  .AM.A  head  reflects  the  true  attitude  of  .American 
doctors  who  respect  their  pledge  to  serve  the  sick  irre- 
spective of  circumstances.  Some  sort  of  better  arrange- 
ment for  medical  care  of  families  of  low  income  is  bound 
to  come.  The  determination  of  the  health  commission  to 
look  realistically  at  all  aspects  of  the  problem  could  be 
greatly  reinforced  by  positive  cooperation  instead  of 
negative  criticism  on  the  part  of  the  medical  association.” 

Dr.  Magnuson,  being  the  type  of  man  he  is, 
will  not  be  deterred  by  criticism  from  carrying 
out  his  assignment.  One  can  therefore  prognosti- 
cate with  more  than  a fair  degree  of  certainty 
that  unless  there  is  a meeting  of  minds  in  regard 
to  the  Commission,  stormy  days  are  ahead. 

In  view  of  this  jirobability  the  personnel  of 
the  Commission  is  of  considerable  interest.  Here 
are  their  names  and  affiliations: 

Dean  .A.  Clark,  .M.D.,  General  Director  of  the  .Massa- 
chusetts General  Hosj)ital,  Boston. 

Joseph  C.  Hinsey,  I’h.D.,  Dean  of  the  Cornell  Univer- 
sity .Medical  College,  New  A'ork. 


100 


In  and  Out  of  Focus — Observer 


FEBRUARY,  1952 


Russel  \'.  Lee,  M.D.,  Associate  Clinical  Professor  of 
Medicine,  Stanford  University  School  of  Medicine,  San 
P'rancisco. 

Evarts  A.  Graham,  M.I).,  surgeon,  St.  Louis,  Mis- 
souri. 

M arion  W.  Sheahan,  R.N.,  Director  of  the  National 
Committee  for  the  Improvement  of  Nursing  Services, 
New  York. 

I'irnest  G.  Sloman,  D.D.S.,  President-elect  of  the 
American  Association  of  Dental  Schools,  San  Francisco. 

Walter  P.  Reuther,  President  of  the  United  Automo- 
bile Workers,  C.I.O.,  Detroit. 

A.  J.  Hayes,  President  of  the  International  Associa- 
tion of  Machinists,  Washington. 

Clarence  Poe,  President  and  editor  of  The  Progressive 
Farmer,  Raleigh,  N.  C. 

Charles  S.  Johnson,  President  of  Fisk  University, 
Nashville. 

Lowell  J.  Reed,  Ph.D.,  Vice  President  of  the  Johns 
Hopkins  University  and  Hospital,  Baltimore. 

Chester  1.  Barnard,  President  of  the  Rockefeller 
Foundation,  New  York. 

Elizabeth  S.  Magee,  General  Secretary  of  the  Na- 
tional Consumers  League,  Cleveland. 


Our  Friend 
Oscar 


In  the  course  of  thirty  years’ 
association  with  the  medical  pro- 
fession, your  Observer  has  be- 
come acquainted  with  hundreds  of  physicians 
throughout  the  country.  As  full-time  secretary  of 
two  urban  medical  societies,  he  has  come  to 
know  many  of  them  intimately.  His  closest  re- 
lationships have  naturally  been  with  officers  and 
committee  members  of  these  organizations  whom 
he  has  observed  under  all  sorts  of  circumstances. 
Without  exception  he  has  found  them  to  be  the 
highest  type  of  professional  men.  Some,  it  is 
true,  possessed  more  talent  for  medical  leadership 
and  organization  work  than  others,  but  all  of 
them  had  one  thing  in  common;  They  were  un- 
selfish in  their  devotion  to  the  organizations  they 
served. 

Dr.  Oscar  B.  Hunter,  whose  recent  death  is 
lamented  by  physicians  in  all  parts  of  the 
country,  ranks  high  on  your  Observer’s  list,  not 
only  as  a doctor  but  as  a man  of  unusual  and 
diverse  talents.  Organizational  problems  were  no 
mystery  to  him  for  he  had  met  and  solved  most 


of  them.  He  understood  the  intricacies  of  finance 
better  than  most  laymen.  But  above  and  beyond 
these,  he  had  vision  and  the  drive  and  the  ability 
to  make  his  dreams  a reality.  Doctors  Hospital 
and  the  surrounding  medical  buildings  are  among 
the  monuments  to  this  dynamic  personality  who 
refused  to  accept  failure  even  when  it  seemed 
inevitable. 

Usually  when  one  says  about  a man  who  has 
recently  died,  that  his  place  cannot  be  filled,  it 
is  little  more  than  a sentimental  e.xpression.  Time 
passes  and  memories  fade,  and  soon  the  person, 
fine  and  able  though  he  was,  is  forgotten  except 
by  his  family  and  close  friends.  Of  Oscar  it  can 
be  truly  said,  his  contributions  to  medicine  and 
the  community  were  so  vital  and  tangible  that 
those  who  are  a part  of  the  present  medical  scene 
will  always  be  conscious  of  the  void  created  by 
his  death. 

Others  will  write  more  eloquently  about  Oscar. 
Your  Observer  only  wishes  to  testify  that  the 
Medical  Society  never  had  a better  friend.  When- 
ever the  Society  called  upon  him  for  help,  and 
that  was  often,  Oscar  responded  willingly  and 
generously.  Incidentally,  few  members  will  ever 
know  how  much  he  gave  in  time  and  money  to 
the  Society.  In  many  instances  projects  spon- 
sored by  our  organization  would  have  failed  had 
it  not  been  for  his  timely  assistance. 

Oscar  should  have  a special  niche  in  the  heart 
of  every  member  of  our  Society,  for  the  Society 
owes  him  much.  As  for  your  Observer,  he  will 
always  remember  Oscar  as  a generous  and  trusted 
friend  who  never  failed  him. 

★ 

It  is  odd  the  things  one  re- 
members. Your  Observer  recalls 
a Methodist  minister  in  a small 
Wisconsin  village  where  he  once  lived  who  had 
been  an  English  instructor  at  the  state  uni- 
versity. The  minister  was  well  thought  of  by 
most  of  his  parishioners,  many  of  whom  were 
impressed  by  his  unusual  educational  qualifica- 
tions. There  were  differences  of  opinion,  as  there 


. .Words  Are 
a Bridge. . .” 


VOL.  XXI,  NO.  2 


Medical  Annals  of  the  District  of  Columbia 


101 


usually  are,  in  regard  to  the  quality  of  his  sermons. 
Some  thought  him  too  highbrow,  others  said  his 
sermons  lacked  depth,  but  on  one  point  they  were 
in  agreement,  he  was  a humdinger  when  it  came 
to  the  use  of  words. 

On  closer  acquaintance  with  the  minister  your 
Observer  discovered  that  words  held  an  unusual 
fascination  for  him.  His  modest  home  was  with- 
out a study  so  he  had  placed  his  large  Webster’s 
Unabridged  Dictionary  on  a pedestal  purchased 
for  the  purpose  in  his  living  room.  There  each 
day  he  devoted  a period  to  his  favorite  pastime, 
enlarging  his  vocabulary. 

Such  a hobby  holds  little  interest  for  most  of 
us,  but  no  matter  how  restricted  our  vocabulary, 
certain  words  arouse  our  deepest  feelings — anger, 
resentment,  enthusiasm  or  affection.  Frequently 
we  become  so  attached  to  certain  words  that  we 
use  them  to  excess.  Your  Observer  recalls  a close 
friend,  a dean  of  a medical  school,  who  had  a 
particular  affinity  to  the  word  “particular”  only 
he  pronounced  it  “perticulor.”  He  used  it  so 
often  it  became  closely  associated  with  him. 

These  and  other  thoughts  on  words  were 
stimulated  by  a highly  interesting  lecture  de- 
livered by  Lady  Violet  Bonham  Carter  before 
the  Royal  College  of  Physicians  in  London  last 
November.*  In  her  opening  remarks  Lady  Carter 
said: 

“There  is  almost  nothing,  good  or  bad,  you 
cannot  do  with  words,  if  only  you  know  how  to 
use  them.  Those  who  are  masters  of  that  subtle 
craft  wield  terrifying  powers,  for  good  and  evil, 
over  the  lives  of  men.” 

She  then  proceeds  to  discuss  three  media  in 
which  words  can  have  a profound  effect:  public 
speaking,  broadcasting  and  books.  Your  Ob- 
server has  culled  the  following  from  her  observa- 
tions. 

On  Public  Speaking 

“I  think  there  are  very  few  ‘golden  rules’  in  public 
speaking.  It  is  an  art  in  which,  more  almost  than  in  any 
other,  everyone  must  work  out  his  own  salvation.  There 

* Published  in  the  Deccml)er  1,  ld51  issue  of  77 e Lmcet 
(London)  under  the  title,  “'the  Power  of  Words.” 


are,  however,  a few  simple  precautions  which  ought  to 
save  one  from  overwhelming  disaster.  I try  to  recall  a 
few  for  my  own  use. 

“First,  try  at  the  very  outset  of  your  speech  to  be- 
tray yourself  somehow  to  your  aurlience.  Get  on  to 
personal  terms  with  them,  and  they  will  forgive  you 
— perhaps  not  everything — but  at  least  a good  deal. 

“Next,  make  them  feel  that  your  speech  is  not  a 
recital  or  a performance  but  a cooperative  business,  a 
partnership  in  which  they  are  playing  an  important 
part;  that  they  are  influencing  it  all  the  time;  and  that 
if  you  were  speaking  to  any  other  audience  in  the  world 
it  would  be  a different  and  probably  a veryinferiorspeech.” 

On  Preparing  to  Speak 

“The  whole  problem  of  preparation  is  again  one  which 
every  individual  must  settle  for  himself.  When  people 
tell  me  that  they  never  prepare  their  speeches  I never 
believe  them.  If  I did  I should  be  very  sorry  for  their 
audiences.  Personally  I think  it  is  an  insult  to  an  audience 
not  to  prepare.  There  is  no  excuse  whatever  for  exposing 
several  thousand  people  to  the  risk  of  one’s  random 
thoughts,  expressed  in  one’s  random  words.  . . . 

“To  be  really  effective  a speech  must  have  form.  It 
must  have  a beginning,  a middle,  and  an  end;  above  all 
it  must  have  a climax.  And  these  things  rarely  fall  into 
their  right  places  by  accident.  Perhaps  the  ideal  recipe 
is  the  one  attributed  to  John  Bright-  ‘You  should  have 
islands — and  swim  between  them.’  ” 

On  Mr.  Churchill 

“Some  of  his  speeches  deserv'e  to  rank  with  those  of 
Pericles,  and  they  will  live  as  long.  And  yet  to  call  them 
‘classics’  does  not  quite  describe  them.  For  Mr.  Churchill 
combines  a classic  form  and  balance  with  a fire  and  colour 
which  are  his  own  alone.  There  lurks  in  every  sentence  the 
ambush  of  the  unexpected.  His  style  has  the  dynamic 
quality  of  action.  Let  us  remember  together  some  words 
of  his  whose  echoes  will  ring  through  English  history. 

‘When  I look  back  on  the  perils  which  have  been 
overcome,  upon  the  great  mountain  waves  through 
which  the  gallant  ship  has  driven,  when  I remember 
all  that  has  gone  wrong,  and  remember  also  all  that 
has  gone  right,  I feel  sure  we  have  no  need  to  fear  the 
tempest.  Let  it  roar,  and  let  it  rage.  We  shall  come 
through.’  ” 

On  Proadcasling 

“It  is  at  once  the  most  universal  and  the  most  inti- 
mate merlium  of  apjjroach  to  human  beings  that  exists. 

“For  though  you  maj'  be  broadcasting  to  millions 
you  are  not  speaking  to  them  in  t ie  mass,  ^■ou  are  not  aj)- 
pealing  to  a crowd  or  a mob.  You  are  speaking  to  them. 


102 


In  and  Out  of  Focus — Observer 


FEBRUARY,  1952 


Calexd.vr  of  Meetings, 

December  16-January  15 

December  17 

Executive  Board 

Obstetrical  Board 

Ruffin  Bequest  Fund  Committee 

December  18 

Grievance  Committee 

D.  C.  Chapter,  .American  .Acad- 
emy of  General  Practice 

December  26 

Medical  Service  of  D.  C. 

January  2 

Executive  Board,  Woman’s  Aux- 
iliary 

January  3 

Section  on  Neurology  and  Psy- 
chiatry 

Executive  Committee,  Gallinger 
Hospital 

January  5 

AA'ashington  Psychoanalytic  So- 
ciety 

January  7 

Committee  on  Revision  of  Eees, 
Medical  Service  of  D.  C. 

January  8 

Committee  on  Public  Health 

Aledical  Officers’  Reserve  Units 

Lay  Society,  Diabetes  Associa- 
tion of  D.  C. 

January  9 

Woman’s  Auxiliary 

January  10 

Washington  Psychiatric  Society 

January  1 1 

Committee  on  Public  Policy 

Section  on  Dermatology  and 
Syphilology 

January  12 

Washington  Psychoanalytic  So- 
ciety 

January  13 

Washington  Orthopedic  Club 

January  14 

Committee  on  Blood  Banks 

House  Committee 

January  15 

Grievance  Committee 

each  one  of  them,  individually  in  the  privacy  of  their 
own  homes.  You  are,  so  to  speak,  having  a simultaneous 
tete-a-tete  with  several  million  people. 

“To  realize  this  fact  is  the  secret  of  good  broad- 
casting. Few  politicians  have  yet  grasped  it,  and  that  is 
why  they  are  so  often  indifferent  broadcasters.  Some  of 
them  are  still  apt  to  treat  the  microphone  as  if  it  were  a 
rostrum  or  a platform  at  a public  meeting.  They  have 
still  to  learn  that  a broadcast  must  not  be  a speech,  or 
a leading  article,  or  an  essay.  It  must  be  a talk. 

“If  you  think  back  to  all  the  most  successful  broad- 
casts you  have  listened  to,  I think  you  will  agree  that 
what  they  hav'e  all  had  in  common  was  this  quality  of 
intimacy — of  naturalness.  The  object  of  a broadcaster 
should  be  to  ‘come  across’  exactly  as  he  is.  In  order  to 


do  this  successfully  he  must  either  be  completely  natural 
and  unselfconscious,  or  else  a very  great  artist  who  can 
appear  so.” 

On  the  Written  Word 

“Once  the  imagination  has  played  its  part  in  creation, 
what  part  is  played  by  words,  by  style,  in  reaching  the 
imagination  of  the  readers? 

“Now  here  we  get  very  varying  opinions  from  various 
writers.  Some  took  endless  pains  with  their  style;  others 
apparently  took  none  at  all.  Samuel  Butler,  for  instance, 
says: 

‘I  should  like  to  put  it  on  record  that  I never  took 
the  smallest  pains  with  my  style,  have  never  thought 
about  it,  and  do  not  know  or  want  to  know  whether 
it  is  a style  at  all.  I cannot  conceive  how  any  man  can 
take  thought  for  his  style  without  loss  to  himself  and 
his  reader.’ 

And  Trollope,  whom  I have  already  quoted,  agreed 
with  him.  Me  thought  that  ‘a  man  who  thinks  too 
much  of  his  words  as  he  writes  them,  will  generally 
leave  behind  him  work  that  smells  of  oil.’  H.  G.  Wells 
said:  ‘I  write  as  I walk,  because  I want  to  get  some- 
where, and  I write  as  straight  as  I can,  just  as  I walk 
as  straight  as  1 can,  because  that  is  the  best  way  to 
get  there.’ 

“Sheridan,  on  the  other  hand,  expressed  the  view  that 
‘easy  writing  makes  damned  hard  reading.’  Walter 
Savage  Landor  said:  ‘I  hate  false  words  and  seek  with 
care,  difficulty  and  moroseness  for  those  that  fit  the 
thing.’  Flaubert  used  to  spend  months  of  agony  trying 
to  compose  a few  sentences. 

‘You  don’t  know  what  it  is’  (he  wrote  to  George 
Sand)  ‘to  stay  a whole  day  with  your  head  in  your 
hands  trying  to  squeeze  your  unfortunate  brain  so 
as  to  find  a word.  . . . .\h,  I certainly  know  the  agonies 
of  style.’ 

“Tolstoy  said  that  ‘One  ought  only  to  write  when  one 
leaves  a piece  of  one’s  flesh  in  the  inkpot  each  time  one 
dips  one’s  pen.’  But  Turgenev  had  a far  rosier  recipe.  He 
said  that  in  order  to  write  he  had  always  to  be  a little 
bit  in  love.  ‘Now  1 am  old  I can’t  fall  in  love  any  more 
and  that  is  why  I have  stopped  writing.’ 

“Well,  would-be  writers — there  you  have  the  dif- 
fering prescriptions  of  these  different  masters  to  choose 
from.  You  can  try  leaving  a bit  of  your  flesh  in  the  ink- 
pot; or,  if  you  prefer  it,  you  can  fall  in  love.” 

In  summing  up,  Lady  Carter  said;  “If  I were 
forced  to  put  into  a few  words  all  that  1 have 
tried  to  say,  I think  it  is  that  words  are  a bridge 
across  both  space  and  time.  Just  as  the  spoken 
word  in  broadcasting  has  conquered  space  and 


VOL.  XXI,  NO.  2 


Medical  Annals  of  the  District  of  Columbia 


103 


made  all  men  our  neighbors,  so  the  written  word, 
preserved  in  books,  has  conquered  and  anni- 
hilated time.” 


_ Dr.  John  W.  Cline  of  San 

. .Our  . 

^ ^ ^ Francisco,  President  of  the 

Greatest  , . , 

Bn liVitvk  American  JVlcclical  AssociatioHj 

is,  without  doubt,  one  of  the 
most  articulate  spokesmen  in  the  history  of  the 
Association.  He  is  an  able  and  forceful  speaker 
who  minces  no  words  in  belaboring  his  op- 
ponents. Few  can  dress  down  so-called  socializers 
more  eloquently  than  he. 

Whether  or  not  one  agrees  with  his  bitter 
denunciation  of  those  who  disagree  with  AMA 
policies,  he  cannot  be  charged  with  being  merely 
an  obstructionist.  On  the  contrary,  physicians 
throughout  the  country  might  well  ponder  the 
following  statement  made  by  him  in  an  address 
before  the  House  of  Delegates  at  Los  Angeles 
last  December.  Dr.  Cline  said: 


“Scientific  medicine  in  the  United  States  has  pro- 
gressed to  a point  never  reached  before  at  any  place  in 
the  world.  Our  standards  of  medical  education  and 
medical  care  have  never  been  equaled  and  these  are  the 
developments  wrought  by  a free  profession  and  educa- 
tional institutions  unhampered  by  governmental  control. 

“The  principal  problem  has  been  and,  to  a large 
extent,  remains  how  best  to  distribute  these  advantages 
to  all  the  people.  In  the  main  the  approach  is  through 
voluntary  health  insurance.  The  growth  and  development 
of  plans  offering  this  coverage  has  been  gratifying.  When 
one  realizes  the  short  space  of  time  in  which  this  has  been 
achieved  it  must  be  considered  to  represent  satisfactory 
progress. 

“More  than  77,()()(),000  people  now  have  some  cover- 
age against  the  costs  of  illness.  About  22,0()(),0()()  are 
enrolled  in  Blue  Shield  and  other  medically  sponsored 
plans  and  44,0()(),()()0  in  Blue  Cross  plans.  This  growth 
has  been  phenomenal.  More  than  half  our  population 
has  protection  from  the  economic  hazards  of  illness. 

“On  the  other  hand  we  must  not  only  expand  the 
numbers  enrolled  but  improve  our  plans.  The  exact 
direction  which  the  improvement  should  follow  is  not 
equally  clear.  As  of  this  time,  no  one  can  say  what  will 
constitute  the  most  desirable  coverage  in  the  future. 
I'he  multiplicity  and  diverse  nature  of  the  plans  creates 


a healthy  situation.  The  very  elasticity  of  the  programs 
permits  and  encourages  experimentation.  The  orderly 
process  of  evolution  will  produce  a form  which  at  some 
future  date  will  be  generally  agreed  upon  as  embodying 
the  most  nearly  ideal  type  of  coverage.  This  process  will 
not  be  limited  by  the  legal  enactments  or  the  arbitrary 
decisions  of  government  agencies  inherent  in  any  scheme 
of  socialized  medicine. 

“Certain  plans  have  developed  catastrophic  coverage 
which  has  proven  workable  and  the  approach  has  been 
somewhat  different  in  various  parts  of  the  country.  More 
needs  to  be  done  in  this  direction  and  unquestionably 
will  be  done. 

‘W  few  plans  have  begun  experiments  designed  to 
include  the  older  age  groups  and  on  an  individual  basis. 
More  must  and  will  be  done  along  this  line.  We  must 
proceed  with  cautious  determination  to  find  methods 
which  will  provide  realistic  coverage  without  endangering 
the  solvency  of  our  plans.  The  experience  gained  by 
numerous  limited  enrollments  ultimately  will  demon- 
strate a satisfactory  method  free  from  the  hazards  of  any 
all-inclusive,  extensive  plans  blindly  applied  to  large 
numbers. 

“The  vast  majority  of  our  members  support  the  pre- 
payment mechanisms  of  distribution  of  the  costs  of 
medical  care,  but  here  and  there,  individuals  and  some 
groups  have  withheld  cooperation  or  give  only  reluctant 
support.  There  can  be  little  question  that  voluntary 
health  insurance  is  our  greatest  bulwark  against  so- 
cialized medicine.  Even  the  proponents  of  socialized 
medicine  clearly  recognize  this.  We  must  have  the  full 
and  vigorous  support  of  the  entire  profession  in  this 
program.” 

Anyone  who  is  familiar  with  the  problems 
confronting  the  physicians  and  laymen  who  are 
endeavoring  to  make  Blue  Shield  plans  work  are 
aware  that  these  statements  are  only  too  true. 

This  is  the  most  critical  period  for  these  plans 
largely  because  of  their  rapid  growth  and  e.xperi- 
mental  nature.  Some  have  weathered  severe  eco- 
nomic storms,  others  will  undoul)tedly  encounter 
them.  But  economic  problems  are  not  the  only 
ones  to  be  hurdled  before  it  can  be  said  that  these 
plans  have  attained  their  maximum  effectiveness. 
Most  of  them  are  still  limited  in  their  coverage  to 
surgery  and  some  medical  care  in  the  hospital.  A 
few  are  endeavoring  to  j)rotect  their  subscribers 
against  the  burdensome  costs  incurred  in  chronic 
illness.  Of  necessity  all  are  moving  forward  con- 
Couliniied  on  page  122) 


C^aleni.a*c  o i Md  ica 


Date 

Society  or  Section 

Program 

Place  and  Time 

March  5 

*Medical  Society  and  Bar 
Association  of  I).  C., 
Joint  Meeting 

Panel  Discussion  on  Medico-legal 

Problems. 

Participants:  Philip  O.  Pelland,  M.D., 
Moderator,  Mr.  William  T.  Hannan, 
Dr.  James  A.  Dusbabek,  and  The 
Honorable  Richmond  Keech,  As- 
sociate Judge,  U.  S.  District  Court 
for  D.  C. 

Medical  Society  Audito- 
rium, 8:00  p.m. 

March  10 

*George  Washington 

University  School  of 
Medicine 

Kellogg  Lecture:  “Practical  Aspects 
of  the  Physiological  Problems  of  the 
Fetus  and  Newborn,”  James  LeRoy 
Wilson,  M.D.,  Professor  of  Pediat- 
rics, University  of  Michigan 

Hall  A,  School  of  Medi- 
cine, 1335  H Street, 
N.W.,  8:30  p.m. 

March  11 

Section  on  Otolaryngol- 
ogy in  joint  meeting  with 
Baltimore  Section 

Speaker:  Paul  H.  Holinger,  M.D., 
Professor  of  Laryngology  and  Bron- 
cho-Esophagology,  University  of  Il- 
linois School  of  Medicine 

Baltimore 

tMarch  12 

*Washington  Psychiatric 

“Use  of  Psychiatric  Teams  in  Civil 
Disaster,”  James  S.  Tyhurst,  M.D.. 
Dalhousie  University,  Halifax 

Medical  Society  Audito- 
rium, 8:30  p.m. 

March  13 

*George  Washington 

University  School  of 
Medicine 

Kellogg  Lecture:  “Therapy  of  the 
Climacteric,”  Francis  Bayard  Car- 
ter, M.D.,  Professor  of  Obstetrics 
and  Gynecology,  Duke  University 

Hall  A,  School  of  Medi- 
cine, 1335  H Street, 
N.W.,  8:30  p.m. 

March  17-19 

*Aero  Medical  Associa- 
tion 

23rd  Annual  Meeting 

Hotel  Statler 

March  17 

OSLER 

Paper:  Philip  J.  Lowenthal,  M.D. 
Case  Report:  H.  Grennan,  M.D. 

Host:  Dr.  John  A.  Wash- 
ington 

March  18 

Clinico-Pathological 

Paper:  Hugo  V.  Rizzoli,  M.D. 

Host:  Dr.  Crenshaw  D. 
Briggs 

March  22 

Washington  Gynecologi- 
cal 

“History  of  Sterility,”  Barton  W.  Rich- 
wine,  M.D.;  “Induction  of  Labor,” 
James  L.  Reycraft,  M.D.,  Assistant 
Clinical  Professor  of  Obstetrics  and 
Gynecology,  Western  Reserve  Lbii- 
versity  School  of  Medicine 

Willard  Hotel,  6:30  p.m. 

March  24 

*Anesthesiologists 

To  be  announced 

Medical  Society  .Audito- 
rium, 8:00  p.m. 

March  24 

*George  Washington 

University  School  of 

Medicine 

Kellogg  Lecture:  “The  Cardiac  Pa- 
tient as  a Surgical  Risk,”  Francis 
Clark  Wood,  M.D.,  Professor  of 
Medicine,  Lhiiversity  of  Penna. 

Hall  .A,  School  of  Medi- 
cine, 1335  H Street, 
N.W.,  8:30  p.m. 

March  24 

Washington  Medical  and 
Surgical 

“The  Surgical  Treatment  of  Cataract,” 
James  Spencer  Dryden,  M.D. 

Case  Report:  C.  W.  Camalier,  Jr.,  M.D. 

Hotel  2400,  6:30  p.m. 

March  29 

*Rheumatism 

“Recent  Advances  in  the  Management 
of  Gout;  the  Use  of  Bencmid,”  Alex- 
ander Gutman,  M.D.,  Professor  of 
Medicine,  College  of  Physicians  and 
Surgeons,  Columbia  University 

Medical  Society  .Audito- 
rium, 8:00  p.m. 

» 

*Open  meetings, 
t Subject  to  change. 

104 


I 


REPORT  OF  DELEGATES  TO  THE  AMA  CLINICAL  SESSION* 


Public  Relations 

For  two  days  before  the  opening  of  sessions  of 
the  House  of  Delegates,  the  AMA  sponsored  a series 
of  talks  and  panel  discussions  in  the  field  of  public 
relations.  The  theme  for  this  fourth  annual  medical 
public  relations  conference  was  “Joining  Forces  for 
Better  PR,”  a theme  intended  to  imply  that  physi- 
cian, county  society,  state  society  and  AMA  must 
work  strongly  together  in  1952.  The  prevailing  tone 
of  the  sessions  this  year  was  less  militant  than  last 
year.  There  seemed  to  be  more  inclination  on  the 
part  of  physicians  to  examine  their  own  motives 
and  actions  critically,  with  a view  to  pleasing  the 
public  and  providing  better  service. 

In  this  same  field  of  medical  public  relations,  we 
were  treated  to  talks  by  Senators  Taft  and  Byrd  in 
a crowded  Shrine  Auditorium  and  learned  mainly 
that  both  of  them  are  “agin”  Truman  because  he 
favors  a kind  of  creeping  socialism  and  spends  too 
much  money.  In  other  talks  by  AMA  President 
John  Cline  and  AMA  Past  President  Elmer  Hender- 
son, we  heard  that  the  AMA  campaign  against 
socialized  medicine  is  becoming  less  and  less  ex- 
pensive. Henderson  pointed  out  that  during  its  first 
year  the  expense  of  the  campaign  was  million 
dollars.  This  rose  to  2^  millions  in  the  second  year, 
which  was  the  peak.  In  this,  our  third  year  of  the 
campaign,  the  cost  will  amount  to  | million,  and 
this  cost  is  expected  to  drop  to  J million  for  next 
year.  The  firm  of  Whitaker  and  Baxter  is  now  being 
retained  on  a kind  of  half-time  consulting  basis. 
At  the  same  time  we  were  urged  by  Dr.  Cline  to 
remember  our  duty  as  citizens.  He  emphasized  that 
our  exercise  of  this  duty  in  the  political  field  next 
year  may  be  of  tremendous  importance  in  deter- 
mining the  course  of  events  in  the  United  States. 
He  also  called  attention  to  the  fact  that  expenditures 
by  the  AMA  in  its  fight  against  socialized  medicine 
have  represented  but  a small  part  of  the  9-million- 
dollar  annual  budget,  most  of  which  is  devoted  to 
councils  and  other  activities  which  are  solely  in  the 
interest  of  providing  the  best  {lossible  medical  care 
for  the  public. 

.-Another  annual  feature  of  the  House  of  Delegates 
is  the  selection  of  the  General  Practitioner  of  the 

* The  Fifth  Clinical  Session  of  the  American  Medical 
Association  was  held  in  Los  .Angeles,  Calif.,  Decemher  4-7, 
1951. 


Year.  The  man  selected  for  the  1951  award  was 
84-year-old  Albert  C.  Yoder  of  Goshen,  Indiana. 
Dr.  Yoder  has  been  a general  practitioner  for  50 
years  and  is  still  going  strong  in  practice.  A day  or 
two  later  when  he  addressed  the  House  of  Delegates 
and  accepted  his  award  from  President  Cline,  he 
seemed  especially  proud  of  his  status  as  a general 
practitioner,  although  he  confessed  that  there  is  a 
need  for  specialists  too. 

\hce  President  Oscar  B.  Hunterf  served  as  official 
host  to  guests  of  the  House  of  Delegates  and  intro- 
duced a number  of  outstanding  men.  One  of  them. 
Dr.  Donald  Wilson,  Commander  of  the  American 
Legion,  spoke  inspiringly  of  the  challenge  which 
arises  from  the  respect  of  the  public  for  medicine, 
of  the  need  for  our  never  being  on  the  defensive 
politically,  and  of  the  warm  support  of  the  American 
Legion  in  the  fight  against  socialization. 

Medical  Education 

For  the  second  consecutive  year  an  announcement 
was  made  of  a contribution  of  J million  dollars  by 
the  AMA  to  the  American  Medical  Education  Foun- 
dation. Although  important  strides  have  been  made 
during  1951  for  the  mobilization  of  private  funds  in 
behalf  of  our  medical  schools,  the  record  of  contribu- 
tions by  individual  physicians  has  been  anything 
but  good.  Only  1,361  individual  physicians  contrib- 
uted during  the  past  year.  This  may  have  been  due 
in  part  to  misunderstandings  about  the  method  of 
utilizing  the  fund.  It  is  now  understood  that  the  cost 
of  collection  and  disbursement  of  the  money  is  under- 
written entirely  by  the  AMA  so  that  all  money 
contributed  goes  intact  to  the  medical  schools.  At 
the  start  the  money  which  is  contributed  to  the 
Foundation  is  placed  in  one  of  two  categories:  (1) 
general  fund,  or  (2)  funds  designated  for  particular 
schools.  The  latter  category  provides  that  an  alum- 
nus who  wishes  his  contribution  to  go  to  his  alma 
mater  may  specify  this  and  has  the  assurance  that 
the  entire  sum  will  be  used  as  he  has  specified.  Nor 
does  this  reduce  the  amount  of  money  which  his 
alma  mater  will  receive  from  the  general  fund,  which 
consists  of  all  unsiiecified  donations.  For  1951  the 
general  fund  was  divided  ecjually  among  all  schools 
in  the  United  States.  It  is  hoped  that  when  the 
general  fund  reaches  a sufficient  size,  other  types  of 


105 


t Died  Dcceml)er  19,  1951. 


106 


Report  of  Delegates  to  AM  A Clinical  Session 


FEBRUARY,  1952 


MEETING  OF  COMMITTEE  ON  BLOOD  BANKS 

Pictured  at)ove  are  members  of  the  AMA’s  Committee  on  Blood  Banks  who  met  on  Sunday  morning,  December  2,  to  dis- 
cuss some  of  the  issues  which  confronted  the  Committee.  Left  to  right  are:  Dr.  James  Reuling,  Bayside,  N.  Y.;  Dr.  Deering 
Smith,  Nashua,  N.  H.;  Dr.  J.  O.  Graves,  Monroe,  La.;  Dr.  James  Stevenson,  Tulsa,  Okla.;  Dr.  John  Green,  Vallejo,  Calif.;  Dr. 
Frank  G.  Dickinson,  Director  of  AMA’s  Bureau  of  Medical  Economic  Research,  Chicago,  111.;  Dr.  Frank  E.  Wilson,  Deputy 
Director  of  .\MA’s  Washington  Office;  Dr.  Herbert  P.  Ramsey,  the  District  Medical  Society’s  senior  delegate  to  the  AMA  and 
Chairman  of  the  Committee;  and  Dr.  L.  W.  Larson,  Bismarck,  N.  D.,  AMA  Trustee. 


contributions  to  the  schools  can  be  made,  (1)  on 
a per  cajrita  basis,  and  (2)  on  the  basis  of  demon- 
strated special  need.  The  House  of  Delegates  was 
urged  to  stimulate  a more  active  interest  in  county 
and  state  societies  in  the  American  Medical  Educa- 
tion Foundation  and  to  work  with  medical  school 
alumni  societies  in  the  same  direction.  Physicians 
generally  were  instructed  to  notify  the  Foundation 
of  contributions  which  they  may  make  directly  to 
medical  schools  in  order  that  the  Foundation  may 
appraise  the  total  contribution  of  United  States 
physicians  to  medical  education.  In  somewhat  the 
same  connection  the  announcement  was  made  that 
a survey  will  be  made  by  the  Board  of  Trustees  of 
the  AMA  of  the  total  problem  of  funds  for  medical 
research. 

A revised  form  of  the  “Essentials  of  an  Acceptable 
Medical  School”  was  presented  by  the  Council  on 
Medical  Education  and  Hospitals,  and  was  approved 
by  the  House.  It  is  noteworthy  that  this  revised 
“Essentials”  accentuates  the  need  for  integration 
of  the  various  components  of  the  curriculum,  and  the 
importance  of  clinical  bedside  teaching  as  opposed 
to  didactic  lectures. 

The  growth  of  the  Student  AMA  was  described, 
and  a brochure  of  its  benefits  and  objectives  was 
distributed.  All  of  the  delegates  were  urged  to  pro- 
mote further  growth  of  this  new  association;  the 
delegates  from  the  Medical  Society  of  the  District 
of  Columbia  received  a special  appeal  from  the 
Council  on  Medical  Education  and  Hospitals  because 


the  schools  in  this  locale  have  not  yet  signified  their 
intention  of  joining  the  association. 

Hospitals 

The  Commission  for  Creditation  of  Hospitals  is 
now  an  established  fact.  It  is  composed  of  six  repre- 
sentatives of  the  American  Hospital  Association, 
three  representatives  of  the  American  College  of 
Surgeons,  three  representatives  of  the  .American  Col- 
lege of  Physicians,  and  six  representatives  of  the 
.American  Medical  .Association.  The  AM.A  appointees 
to  this  Commission  are  Drs.  Gundersen,  Truman, 
Murray,  Weiskotten,  Whitacre,  and  Price.  The  exact 
method  of  function  of  the  Commission  remains  to 
be  worked  out.  However,  it  is  apparent  that  a large 
part  of  its  financial  support  will  come  from  AM.A 
funds.  .And  it  is  understood  that  representatives  of 
the  .American  Hospital  .Association  will  be  concerned 
more  intimately  with  factors  of  hospital  adminis- 
tration, while  the  medical  men  on  the  commission 
will  be  concerned  with  the  quality  of  medical  service 
in  the  hospital. 

.A  report  from  the  Board  of  Trustees  on  the 
relation  of  physicians  and  hospitals  was  issued  to 
replace  prior  reports,  including  the  Hess  report. 
The  Board  report  was  approved  by  the  House  of 
Delegates.  It  upholds  the  stand  of  jirevious  reports 
that  a physician  should  not  dispose  of  his  profes- 
sional attainments  or  services  to  any  hospital  or 
institution  under  conditions  whereby  such  services 


VOL.  XXI,  NO.  2 


Medical  Annals  of  the  District  of  Columbia 


107 


are  resold.  It  holds  physicians  alone  accountable  for 
violations  of  this  code  and  contains  no  threat  of 
punitive  action  against  a transgressing  hospital. 

Also  in  the  hospital  field  a resolution  was  passed 
regarding  the  desirability  of  approving  internships 
on  the  basis  of  the  training  facilities  available,  and 
the  increase  in  the  number  of  general  practice  resi- 
dencies now  available  was  commended. 

Public  Health 

In  this  field  there  were  several  outstanding  items. 
First  was  the  report  of  the  Committee  on  Blood 
Banks,  which  is  among  the  important  reports  given 
at  sessions  of  the  House.  The  report  at  this  session 
was  delivered  by  Dr.  Ramsey  and  emphasized  the 
need  for  publicizing  the  contraindications  as  well 
as  the  indications  for  the  use  of  blood  and  blood 
derivatives,  urged  better  cooperation  on  the  part 
of  physicians  in  the  matter  of  insuring  that  blood 
bank  reserves  are  replenished,  advocated  the  issu- 
ance of  blood  type  cards  to  donors,  and  strongly 
advised  the  integration  of  all  available  blood  bank 
facilities  into  the  national  program. 

The  House  also  went  on  record  as  approving 
fluoridation  of  water  for  the  prevention  of  dental 
caries  and  gave  its  support  to  a campaign  for  warn- 
ing the  public  about  common  household  products 
which  contain  poisonous  ingredients  and  are  never- 
theless not  labeled  as  poisons.  With  regard  to  such 
poisons,  it  was  announced  that  they  will  be  brought 
to  the  attention  of  the  public  in  Today's  Health. 

A resolution  was  passed  approving  the  idea  of 
having  the  Government  purchase  voluntary  health 
insurance  for  the  needy  dependents  of  men  in  mili- 

INCREASED  RATES  FOR  BLUE 

Xew  rates  which  become  effective,  March  1,  for 
participants  in  (iroup  Hos[)italization  and  Medical 
Service  reflect  the  rising  medical  costs.  Some  bene- 
fits have  been  added. 

Individual  contracts  for  Hospital  service  will  be 
SI. 70  a month  fan  increase  of  40  cents);  family  con- 
tracts, Sd.70  per  month  fan  increase  of  70  cents); 
individual  contracts  for  Surgical  service,  SI. 00  i)er 
month  (no  increase);  family  contract,  S.k20  fan 
increase  of  50  cents). 

i 


tary  service,  through  Blue  Shield  and  medical  so- 
ciety-sponsored plans. 

A number  of  items  connected  with  veterans  care 
were  discussed,  and  all  ramifications  of  this  problem 
were  referred  to  a special  committee  of  the  Board  of 
Trustees  for  further  report.  No  statement  of  policy 
was  made  on  the  matter  of  the  care  of  veterans  with 
nonservice-connected  disabilities  in  \'eterans  Admin- 
istration hospitals. 

Internal  Affairs 

A report  was  made  by  a special  committee  which 
had  surveyed  the  organizational  structure  of  stand- 
ing committees  of  the  House  of  Delegates.  The  idea 
w'as  approved  that  standing  committees  and  councils 
of  the  House  of  Delegatesare  answ'erable  to  the  Board 
of  Trustees,  which  in  turn  is  answerable  to  the  House 
of  Delegates.  The  committee  commended  the  idea 
of  a limited  term  of  office  for  members  of  standing 
committees  and  councils. 

Miscellaneous  items  included  approval  of  a sub- 
stantial honorarium  for  the  president  of  the  AMA; 
spade  work  for  the  passage  of  amendments  in  the 
coming  June  meeting  for  the  purpose  of  establishing 
a single  class  of  membership;  announcement  of  the 
intention  to  enlarge  the  Washington  Office  and  to 
purchase  permanent  quarters  for  this  Office  when 
feasible;  protest  against  any  Government  policy  of 
deferment  of  chiropractic  students  from  military 
service;  and  a formal  announcement  that  the  ne.xt 
(1952)  Clinical  Session  will  be  held  next  December  in 
Denver. 

Herbert  P.  Ramsey,  M.D. 

Hugh  H.  Hussey,  M.D. 

Delegates 

CROSS-BLUE  SHIELD  PLANS 

Increase  in  Hospital  Benefits 

When  a subscriber  is  admitted  to  a participating 
hosjiital,  21  days  of  hospital  care  will  be  provided 
with  full  service  benefits  in  semi-private  accommo- 
dations, plus  180  additional  days  with  an  allowance 
of  S5  a day,  or  a total  of  201  benefit  days  for  each 
confinement.  Benefit  days  will  be  fully  renewed  90 
days  after  discharge  from  the  hospital  but  read- 
mission to  the  hospital  within  90  days  shall  be  con- 
sidered one  confinement. 


I 


108 


XeW  Assislani  Director  of  Public  Health 


FEBRUARY,  1952 


For  the  first  time,  a subscriber  may  procure  full 
service  benefits  when  hospitalized  away  from  the 
Washington  area,  provided  he  is  admitted  to  one  of 
4,500  hospitals  over  the  Nation  that  participate  in 
the  Blue  Cross  program.  If  hospitalized  in  a non- 
participating hospital,  the  subscriber  will  get  in- 
creased allowance  ranging  from  $21  for  the  first 
day  of  hospital  care  to  $274  for  21  days. 

.■\n  allowance  up  to  $10  is  provided  for  outpatient 
service  when  the  subscriber  is  not  a bed  patient  for 
(1)  emergency  first  aid  within  two  hours  after  an 
accident,  or  (2)  use  of  operating  room  facilities  when 
a general  anesthetic  is  used. 

When  the  participant  is  accepted  for  treatment 
by  a general  hospital,  up  to  10  days’  care  will  be 
provided  for  pulmonary  tuberculosis  and  mental  or 
nervous  disorders  during  any  12  consecutive  months. 

Change  in  Maternity  Beneeits 

The  revised  Family  contract  will  offer  an  allow- 
ance of  uji  to  $9  a day  for  a maximum  of  8 days  of 
hospital  care  for  any  one  pregnancy,  these  revised 


benefits  to  become  effective  October  1,  1952.  Full 
hospital  service  benefits  will  be  provided  for  cesa- 
rean deliveries,  termination  of  ectopic  pregnancies, 
and  miscarriages. 

Increase  in  Surgical  Benefits 

For  the  first  time  subscribers  to  the  Surgical 
Service  Plan  will  receive  benefits  for  the  following 
currently  specified  services  rendered  in  the  home  or 
in  the  doctor’s  office:  emergency  treatment  of  frac- 
tures and  dislocations;  sujierficial  tumors  and  cysts; 
external  thrombosed  hemorrhoids;  suturing  lacera- 
tions (up  to  $15);  nasal  polyp  removal;  chalazion 
removal;  probing  tear  duct  (initial);  and  circum- 
cision. 

The  income  levels  have  also  been  increased.  The 
benefits  offered  by  the  Surgical  contract  will  cover 
in  full  the  physician’s  charge  for  services  for  a single 
participant  if  his  income  does  not  exceed  $3,000  and 
for  a family  participant  if  the  income  does  not  ex- 
ceed $5,500. 


DR.  HEATH  APPOINTED  ASSISTANT  DIRECTOR  OF  PUBLIC  HEALTH 


The  appointment  of  Dr.  Frederick  C.  Heath, 
M.I).,  M.P.H.,  as  Assistant  Director  of  Public 
Health,  D.  C.  Health  Department,  was  announced 
January  10,  1952,  by  Dr.  Daniel  L.  Seckinger, 
Director  of  Public  Health.  The  position  has  been 
filled  temporarily  by  Dr.  Arthur  E.  Cliff  since 
August,  1950.  Dr.  Seckinger  stated:  “Dr.  Heath 
will  give  to  the  Department  material  assistance  in 
its  increasing  scope  of  activities  and  responsibilities. 
His  appointment  will  help  the  Director  of  Public 
Health  to  more  adequately  coordinate  the  jireven- 
tive  phases  of  our  activities  with  the  medical  care 
responsibilities  and  other  major  health  problems, 
including  civil  defense.” 

A native  of  Cecil  ('ounty,  Maryland,  Dr.  Heath 
graduated  from  Hahnemann  College  of  Science, 
pre-medical,  in  1925.  His  medical  degree  was  re- 
ceived at  Hahnemann  Medical  School,  Philadelphia, 
in  1929,  following  which  he  interned  at  the  Com- 
munity Ceneral  Hospital  in  Reading,  Pennsylvania. 
While  engaged  in  general  practice.  Dr.  Heath  be- 
came associated  with  public  health  as  jihysician  to 


several  industrial  plants  in  Berks  County,  Pennsyl- 
vania, until  .August,  1942. 

Entering  the  .Army  as  a Captain,  Dr.  Heath 
served  as  Battalion  Surgeon  and  .Assistant  Com- 
mand Surgeon,  Engineers  Command,  in  the  Medi- 
terranean Theatre  of  Operations  until  late  in  1945. 

From  December  1,  1945  to  December  1,  1950  he 
was  health  officer  for  the  (files,  Montgomery,  and  , 
Radford  districts  in  X'irgina.  He  is  resigning  his 
present  position  as  Health  Officer  of  Fairfax  County, 
\firginia,  which  he  has  held  since  December,  1950,  . 
to  accept  this  new  assignment.  \\'hile  at  Fairfax  i 
he  was  responsible  for  developing  a jirogram  relating  • 
to  the  health  in  the  subdivision  developments  in 
that  county,  and  its  sewage  and  water  facilities. 
The  health  budget  was  doubled  in  the  year  he  , 
serv’ed  there  and  the  sanitation  personnel  increased  ; 
90  per  cent;  nursing  services,  40  per  cent.  He  was  j 
instrumental  in  revising  the  school  health  program  ' 
to  bring  it  up  to  present  standards  set  by  large  | 
cities.  Two  health  centers  were  established  in  the  ■ 
county  during  his  regime,  one  at  Penn-Daw  and  ; 
one  at  Falls  Church. 


DENTISTRY 


THE  EDUCATION  OF  A DENTIST* 


Gerard  J.  Casey,  D.D.S. 

Assistant  Secretary,  Council  on  Dental  Education,  American  Dental  Association 


The  grass  roots  of  an  education  of  a dentist  are 
founded  in  the  thousands  of  secondary  schools 
throughout  the  country,  and  are  further  nourished 
in  the  hundreds  and  hundreds  of  cultural  campuses 
of  the  many  junior  colleges,  colleges  and  universities 
that  function  from  coast  to  coast. 

Thousands  and  thousands  of  students  find  their 
first  inklings  of  interest  in  a dental  professional 
career  while  in  high  school.  The  student  who  finds 
his  interest  centering  upon  the  dental  profession 
cannot  begin  too  early  to  plan  the  educational  proc- 
ess. It  is  evident  that  a four-year  high  school  course 
must  be  comjileted  in  order  to  gain  admission  to  a 
liberal  arts  college.  The  student  even  at  this  point 
should  write  to  the  registrar  of  the  college  or  uni- 
versity he  intends  to  enter  so  that  he  or  she  may 
plan  and  complete  the  necessary  high  school  courses 
necessary  for  entrance  to  college.  The  student  should 
also  write  to  the  dental  school  or  schools  in  which  he 
is  interested  and  obtain  from  them  the  catalogues 
that  give  all  the  necessary  information  for  admission 
to  dental  school,  since  several  of  the  dental  schools 
require  certain  courses  to  be  pursued  in  the  high 
school  course.  However,  most  of  the  schools  do  not 
directly  specify  high  school  requirements  in  their 
catalogues,  but  clearly  assume  that  the  student 
must  satisfy  the  requirements  for  admission  to  the 
liberal  arts  college  in  which  he  projroses  to  prepare 
for  dental  study. 

Predextal  R equire.\iext.s 

The  minimum  requirement  of  two  academic  years 
of  liberal  arts  study,  [)rescribed  by  the  Council  on 
Dental  liducation,  is  observed  by  all  the  flental 
schools.  There  is  no  short-cut  in  the  path  to  a 
dental  career.  The  college  requirement  covers  at 
least  60  semester  hours  or  one  half  the  requirements 

* Kditor’s  Notk:  This  is  the  first  of  a series  of  articles 
I designed  to  acquaint  physicians  with  the  activities  and  proh- 
\ lems  of  those  in  the  ancillary  branches  of  medicine. 


for  the  bachelor’s  degree.  It  is  possible,  therefore, 
for  a student  in  an  accredited  junior  college  to  com- 
plete the  requirements  for  admission  to  dental 
school.  However,  the  student  offering  only  two  years 
of  predental  work  must  have  taken  in  the  college 
course  one  year  of  English,  biology,  physics  and 
inorganic  chemistry.  A one-half  year  course  in  or- 
ganic chemistry  is  necessary.  All  of  these  courses 
must  show  at  least  minimum  passing  credit.  There- 
fore, it  is  important  that  the  student  knows  in  ad- 
vance the  courses  required  and  that  he  sees  to  it  that 
his  curriculum  contains  the  courses  mentioned,  so 
that  upon  presentation  of  his  credits  to  the  dental 
school  admission  office  they  will  be  given  considera- 
tion. 

Sometimes  students  desire  to  study  dentistry 
after  they  have  conifileted  three  years  of  college 
work  or  have  even  graduated  from  college  but  find 
that  they  have  no  credit  in  biology  or  physics.  The 
Council  on  Dental  Education  of  the  American 
Dental  .•\ssociation  permits  deviations  from  the  [)re- 
scribed  requirements  in  biology  and  physics  but 
not  in  any  case  in  English  and  chemistry.  Formal 
credit  in  biology  and  or  physics,  but  not  in  English 
or  chemistry,  may  be  waived  in  the  case  of  sui)erior 
students  (a  “B-fi”  average  or  better)  with  three  or 
more  years  of  college  credit  earned  in  an  accredited 
college.  About  half  of  the  dental  schools  observ^e 
this  permissive  regulation. 

The  requirements  here  outlined  are  ])rescribed 
on  a minimum  basis.  Several  schools  e.xact  higher 
requirements.  Some  schools  now  require  three  years 
of  liberal  arts  work  for  admission  and  some  others 
extend  the  subject  re(|uirements.  It  is,  therefore, 
important  for  the  student  as  soon  as  he  decides  upon 
a career  in  dentistry  to  make  sure  that  his  liberal 
arts  course  is  satisfactory.  Students  should  also 
recognize  the  fact  that  many  applicants  to  dental 
study  offer  more  than  the  minimum  recjuirements. 

'I'he  daily  lifework  of  the  dentist  is  restricted  to 


no 


Education  of  a Dentist— Casey 


FEBRUARY,  1952 


a relatively  narrow  field  of  human  interest  and  ex- 
perience. Therefore,  in  the  preliminary  studies  in 
high  school  and  college  the  student  would  do  well  to 
broaden  his  general  education  as  widely  as  possible. 
The  studies  in  a dental  school  are  of  necessity  highly 
technical  and  highly  specialized.  It  is  in  high  school 
and  college  that  the  student  must  lay  the  ground- 
work for  such  future  interest  and  satisfaction  as  he 
may  desire  from  formal  basic  education  in  language 
and  literature,  history,  government,  mathematics, 
economics,  psychology,  sociology,  and  the  arts.  It 
is  generally  regarded  as  unwise  for  a prospective 
dental  student  to  overload  his  predental  program 
with  the  sciences  which  are  preliminary  to  dental 
study.  The  minimum  science  requirement  should  be 
met  with  thoroughness  and  fidelity  with  a choice 
of  electives  which  will  enrich  his  cultural  back- 
ground. His  predental  education,  if  wisely  planned 
and  followed,  will  go  far  toward  enabling  the  stu- 
dent to  make  satisfying  use  of  his  leisure  time. 

By  an  accredited  liberal  arts  college  the  Council 
on  Dental  Education  of  the  American  Dental  Asso- 
ciation means  an  institution  approved  by  the  Asso- 
ciation of  American  Universities  or  by  one  of  the 
regional  accrediting  agencies. 

The  admission  of  a student  to  a dental  school 
from  a liberal  arts  college  not  within  the  territory 
or  jurisdiction  of  an  accrediting  body  may  be  sanc- 
tioned by  the  Council  in  extraordinary  or  special 
cases  after  ample  evidence  has  been  furnished  con- 
cerning the  quality  and  character  of  the  instruction 
of  the  institution  in  question.  A limited  number  of 
students  may  also  be  admitted  from  unaccredited 
institutions  provided  the  credits  earned  are  accept- 
able toward  its  degree  by  the  state  university  of  the 
state  in  which  the  unaccredited  colleges  are  located. 
The  student  should  have  no  doubt  about  the  accept- 
ability of  the  liberal  arts  college  in  which  he  is  en- 
rolled. Advice  from  the  dental  school  should  be 
sought  concerning  this  matter. 

The  Dental  Aptitude  Testing  Program 

Up  to  this  point  we  have  been  concerned  with  the 
student  as  he  went  about  his  high  school  and  college 
courses.  Thousands  of  students  submit  appilications 
to  the  offices  of  admissions  of  the  dental  schools 
throughout  the  land.  And  the  foremost  question  in 
the  mind  of  all  concerned  is,  “Who  should  enter 
dental  school?”  “In  order  to  enter  any  of  the 


accredited  professional  schools  the  applicant  must 
give  evidence  to  the  admission  officials  that  he  or 
she  will  probably  be  a credit  to  that  institution.  Not 
all  professions  demand  the  same  kind  of  evidence, 
and  not  even  all  schools  in  a given  profession  have 
the  same  requirements  and  hold  to  the  same  stand- 
ards of  proficiency. 

“All  dental  schools  subscribe  to  the  same  basic 
requirements  by  insisting  on  a minimum  of  two 
years  of  acceptable  college  work  which  includes  cer- 
tain specific  courses;  but  this  is  not  the  only  entrance 
requirement.  The  additional  requirements  are  not 
the  same  for  all  schools,  but,  in  most  instances, 
they  include  a careful  evaluation  of  the  applicant’s 
academic  record  of  both  high  school  and  college,  a 
study  of  his  letter  of  recommendation  and  a per- 
sonal interview  if  it  is  at  all  practicable. 

“Many  of  the  dental  schools  study  their  appli- 
cants’ qualifications  still  more  carefully  and  utilize 
various  means  in  an  effort  to  predict  which  of  their 
applicants  are  most  likely  to  succeed  in  their  school 
and  later  in  the  profession  of  dentistry.” 

The  Council  on  Dental  Education  of  the  .Ameri- 
can Dental  .Association,  with  the  .American  .Asso- 
ciation of  Dental  Schools,  has  interested  itself  in 
the  subject  of  predicting  dental  student  success. 
The  Committee  on  Dental  .Aptitude  Testing,  com- 
posed of  representatives  of  both  these  and  under  the 
direction  of  Shailer  Peterson,  Ph.D.,  Secretary  of 
the  C'ouncil  on  Dental  Education,  inaugurated  a 
mental  and  manual  aptitude  testing  program  cal- 
culated to  help  answer  the  often  perplexing  question 
as  to  who  should  study  dentistry,  d'he  first  phase  of 
this  program  was  an  experimental  program  in  apti- 
tude testing  which  was  begun  in  1946  and  has  as  its 
objectives: 

1.  To  measure  the  student’s  ability  to  read  with 
understanding  the  type  of  material  that  he  will  be 
expected  to  read  in  dental  school. 

2.  To  measure  the  student’s  ability  to  memorize 
verbal  and  visual  material. 

d.  To  measure  the  student’s  knowledge  of  word 
meanings,  both  general  and  scientific  vocabulary. 

4.  To  measure  the  student’s  mental  ability  and 
to  secure  measurement  on  his  ability  to  reason,  as 
well  as  part  scores  on  his  linguistic  and  quantitative 
abilities. 

5.  To  measure  the  student’s  ability  to  visualize 
patterns  and  relations  without  the  necessity  of  jire- 


VOL.  XXI,  NO.  2 


Medical  A nnals  of  the  District  of  Columbia 


111 


paring  drawing  of  all  these  relations.  Associated  with 
this  is  the  objective  to  measure  the  student’s  appre- 
ciation of  artistic  design. 

6.  To  measure  the  student’s  ability  to  express 
himself  orally  and  in  writing. 

7.  To  measure  the  student’s  ability  to  use  his 
hands  and  fingers  skillfully  and  dexterously. 

This  experimental  program  proved  so  successful 
that  all  of  the  dental  schools  elected  to  require  all 
their  applicants  to  take  the  aptitude  tests  prior  to 
admission.  The  first  Nation-wide  dental  aptitude 
testing  program  for  applicants  to  the  dental  schools 
was  inaugurated  the  latter  part  of  1950  for  the  appli- 
cants for  the  1951  class.  A brochure  on  the  dental 
aptitude  testing  program  may  be  had  by  writing 
to  the  American  Dental  Association,  Division  of 
Aptitude  Testing,  222  East  Superior  Street,  Chicago 
11,  Illinois. 

It  should,  therefore,  be  of  great  interest  to  pro- 
spective students  of  dentistry  to  know  that  the  suc- 
cess of  dental  students  in  their  basic  science  courses 
can  be  predicted  with  considerable  accuracy  by 
such  things  as  (1)  general  intelligence,  (2)  reading 
ability  in  the  sciences,  and  (3)  ability  to  ap[)ly 
scientific  principles.  Achievement  in  the  clinical  and 
preclinical  subjects  can  be  predicted  by  abilities 
demonstrated  in  (1)  visualization  of  three  dimen- 
sional patterns,  and  (2)  manual  operations  such  as 
carving. 

The  next  question  to  arise  is,  when  do  the  stu- 
dents participate  in  this  dental  aptitude  test.  Usu- 
ally the  student  takes  the  aptitude  test  during  his 
second  year  of  college  predental  studies  because  he 
or  she  will,  by  the  following  June,  have  finished  the 
minimum  requirements  for  entrance  into  a dental 
school,  and  thus  will  be  eligible  for  the  first  time 
for  consideration  by  the  dental  school  to  become  a 
dental  student. 

The  search  today  in  the  academic  world  is  for  the 
man  behind  the  credentials.  The  outlook  is  hope- 
fully for  more  and  more  emphasis  upon  the  human 
equation  at  the  entrance  of  our  professional  schools 
with  no  lessening  of  the  requirement  of  a negotiable 
documentary  record.  f)ur  j)rofessional  schools  are 
everywhere  alert  to  the  new  movements  in  all  phases 
;of  education  on  the  university  level.  Thus,  today 
t with  all  these  instruments  of  evaluation  it  is  hoped 
that  the  admission  committees  of  the  dental  schools 
jwill  be  able  in  their  consideration  of  applicants  to 
1 more  and  more  find  the  man  behind  the  credentials. 


The  Professional  Course  of  Study 

After  the  student  has  completed  the  predental 
requirements  and  has  gained  admission  to  a dental 
school,  he  must  e.xpect  to  spend  four  academic  years 
in  dental  study.  Fortunately  for  the  profession  there 
is  no  substandard  dental  school  in  the  United  States. 
All  schools  observe  the  minimum  predental  and  pro- 
fessional requirements  prescribed  by  the  Council  on 
Dental  Education. 

Most  of  the  schools  confer  the  degree  of  Doctor 
of  Dental  Surgery  (D.D.S.)  upon  candidates  who 
complete  the  professional  course,  and  four  schools 
confer  the  degree  of  Doctor  of  Dental  Medicine 
(D.M.D.).  The  dental  profession  and  state  dental 
licensing  boards  recognize  no  distinction  in  inherent 
values  as  between  these  two  degrees.  In  the  majority 
of  the  universities  in  which  dental  schools  form  an 
integral  part,  it  is  possible  for  the  individual  student 
in  combined  courses  to  earn  the  degree  of  Bachelor 
of  Arts  (A.B.)  or  the  degree  of  Bachelor  of  Science 
(B.S.)  and  the  professional  degree  of  D.D.S.  or 
D.M.D.  in  six  or  seven  years.  It  is  also  possible  in 
some  instances  for  the  individual  student  to  earn 
the  degree  of  Bachelor  of  Science  in  Dentistry  (B.S. 
in  D.)  in  connection  with  the  professional  course 
by  offering  credit  in  certain  specified  subjects  in 
liberal  arts  and  science. 

Medical  and  Hospital  Relationships 

The  majority  of  the  dental  schools  depend  in 
whole  or  in  part  upon  their  associated  medical  schools 
for  the  teaching  of  the  basic  science  subjects.  Medical 
and  dental  students  are  taught  these  subjects  to- 
gether in  only  a few  schools,  and  the  first  two  years 
of  the  dental  course  are  identical  with  the  medical 
course  in  only  one  institution.  Integration  between 
medical  and  dental  schools  in  the  field  of  the  sciences 
has  not  reached  the  point  where  transfer  of  credit 
is  readily  possible.  If  the  student  is  interested  in  se- 
curing degrees  in  both  medicine  and  dentistry,  he 
would  do  well  to  ascertain  from  the  university  he 
proposes  to  enter  the  possibility  of  shortening  the 
usual  time  to  secure  the  two  degrees.  While  believing 
that  the  dental  teaching  program  in  the  basic  sci- 
ences should  make  use  of  all  the  facilities  the  uni- 
versity possesses  in  this  field,  the  Council  urges 
that  in  the  conduct  of  the  entire  dental  curriculum 
administrative  autonomy  should  be  maintained. 


AM  A Dues  for  A)  5 2 


FEBRUARY,  1952 


1 12 

Hospital  Dental  Internships  and 
Residencies 

Marked  interest  has  been  shown  in  recent  years 
in  improvements  in  the  general  health  service  of 
many  hospitals  by  the  establishment  of  dental  in- 
ternships and  residencies.  A growing  number  of 
dental  graduates  seek  one  or  more  years  of  hos- 
pital experience  before  beginning  dental  practice  on 
their  own  account  or  engaging  in  teaching  or  re- 
search. Delaware  is  the  only  state  which  specifies 
by  statute  the  requirement  of  a year’s  internshi[) 
before  a dental  graduate  may  be  admitted  to  the 
licensing  examination.  Both  the  American  Dental 
•Association  and  the  American  Hospital  Association 
have  taken  steps  to  promote  and  strengthen  hospi- 
tal dental  internships  and  residencies. 

In  194d  the  Council  on  Dental  Education  ap- 
pointed a special  committee  to  formulate  require- 
ments for  the  approval  of  hospital  dental  intern- 
ships and  residencies,  and  in  1944  the  House  of 
Delegates  of  the  American  Dental  Association 
authorized  the  appointment  of  a Committee  on 
Hospital  Dental  Service.  As  of  February  26,  1946 
the  Council  adopted  requirements  for  the  approval 
of  hospital  dental  internshi[)s  and  residencies.  The 


Council  has  an  approved  list  of  hospitals  and  sana- 
toriums  for  the  training  of  dental  interns  and  resi- 
dents. This  list  may  be  obtained  upon  request. 
Additional  hospitals  will  be  added  to  the  list  as  the 
Council  proceeds  with  its  inspections. 

After  the  student  has  satisfied  the  dental  faculty 
as  to  his  requirements  in  the  dental  curriculum  he 
is  recommended  to  the  university,  and  the  dental 
degree  (LD.D.S.  or  D.M.D.)  is  conferred  upon  him. 

He  now  stands  on  another  threshold.  He  is  ready 
to  begin  his  professional  career  and  his  service  to 
his  community.  In  order  to  accomplish  this  he  must 
first  ajiply  to  the  state  dental  board  of  whatever 
state  he  intends  to  practice  and  take  the  qualifying 
examination  and  pass  it.  He  then  receives  his  license 
to  practice.  And  thus  he  serves.  But  he  has  not  left 
his  student  days  behind.  Each  day  in  practice  brings 
a new  problem  for  which  a solution  must  be  brought 
forth.  And  thus  the  practitioner  again  becomes  a 
student,  sometimes  in  his  home  with  a textbook, 
sometimes  by  taking  a refresher  course  at  the  den- 
tal school  or  one  given  by  the  dental  society  study 
club,  and  sometimes  by  attending  clinics  and  seeing 
the  actual  demonstration  of  the  point  in  question. 
The  education  of  a professional  man  is  never  ended. 
It  is  always  beginning. 


FACTS  ABOUT  AM  A DUES  FOR  1952 


1.  American  Medical  Association  membership  dues 
for  1952  are  825.00. 

2.  Fellowship  dues  for  1952  have  been  abolished. 

3.  AMA  membership  dues  are  levied  on  “active” 
members  of  the  Association.  A member  of  a con- 
stituent association  who  holds  the  degree  of  Doctor 
of  Medicine  or  Bachelor  of  Medicine  and  is  entitled 
to  exercise  the  rights  of  active  membership  in  his 
constituent  association,  including  the  right  to  vote 
and  hold  office  as  determined  by  his  constituent 
association,  and  has  paid  his  AMA  dues,  subject 
to  the  provisions  of  the  By-laws,  is  an  “active” 
member  of  the  Association. 

4.  AMA  membership  dues  are  payable  through 
the  component  county  medical  society  or  the  con- 
stituent state  or  territorial  medical  association,  de- 
pending on  the  method  adopted  locally. 

5.  Commissioned  medical  officers  of  the  United 
States  Army,  the  United  States  Navy,  the  United 
States  Air  Force,  or  the  United  States  Pulilic  Health 


Service,  who  have  been  nominated  by  the  Surgeons 
General  of  the  respective  services,  and  the  permanent 
medical  officers  of  the  \'eterans  Administration  and 
the  Indian  Service,  who  have  been  nominated  by 
their  C'hief  Medical  Directors,  may  become  Service 
Fellows  on  ajiproval  of  the  Judicial  Council  Service 
Fellows  need  not  be  members  of  the  component 
county  or  constituent  state  or  territorial  associations 
or  the  American  Medical  Association.  They  do  not 
receive  any  publication  of  the  AMA  except  by  per- 
sonal subscription.  If  a local  medical  society  regula- 
tion permits,  a Service  Fellow  may  elect  to  become 
an  active  member  of  a component  and  constituent 
association  and  the  American  Medical  Association, 
in  which  case  he  would  pay  the  same  membership 
dues  as  any  other  active  member  and  receive  a sub- 
scription to  The  Journal  of  the  American  Medical 
Association. 

6.  An  active  member  of  the  American  Medical 
Association  may  be  excused  from  the  payment  of 


VOL.  XXI,  NO.  2 


Medical  Annals  of  the  District  of  Columbia 


113 


AMA  membership  dues  when  it  is  deemed  advisable 
Iry  the  Board  of  Trustees,  provided  that  he  is  par- 
tially or  wholly  excused  from  the  jmyment  of  dues 
by  his  component  society  and  constituent  associa- 
tion. 

The  following  may  be  excused  in  accordance  with 
this  provision:  (a)  members  for  whom  the  payment 
of  dues  would  constitute  a financial  hardship  as 
determined  by  their  local  medical  societies;  (b)  mem- 
bers in  actual  training  but  not  more  than  five  years 
after  graduation  from  medical  school;  (c)  members 
who  have  retired  from  active  practice;  (d)  members 
who  have  reached  the  age  of  70,  on  request,  and 
starting  January  1 following  the  70th  birthday,  and 
(e)  members  who  are  called  to  active  duty  with  the 
armed  forces  (exemption  begins  July  1 or  January  1 
following  entrance  on  active  duty).  The  last  two 
categories  are  excused  from  AMA  dues  regardless 
of  local  dues  exemptions. 

7.  Active  members  of  the  American  Medical  Asso- 
ciation are  not  excused  from  the  payment  of  AMA 
membership  dues  by  virtue  of  their  classification  by 
their  local  societies  as  “honorary”  members  or  be- 
cause they  are  excused  from  the  payment  of  local 
and  state  dues.  Active  members  may  be  excused 
from  the  payment  of  AMA  membership  dues  only 
under  the  provision  described  in  paragraph  6 above. 

8.  .AMA  membership  dues  include  subscription  to 
The  Journal  of  the  American  Medical  Association. 
.Active  members  of  the  .Association  who  are  e.xcused 
from  the  payment  of  dues  will  not  receive  The  Jour- 
nal e.xcept  by  personal  subscription  at  the  regular 
subscription  rate  of  $15.00  a year. 

9.  Members  may  substitute  one  of  the  special 
journals  published  by  the  Association  for  The  Jour- 
nal to  which  they  are  entitled  as  members. 

10.  A member  of  the  .AMA  who  joins  the  Associa- 
tion on  or  after  July  1 will  pay  membership  dues 
for  that  year  of  $12.50  instead  of  the  full  $25.00 
membership  dues. 

11.  .An  active  member  is  delinquent  if  his  dues  are 
not  paid  by  June  1 of  the  year  for  which  dues  are 
prescribed  and  shall  forfeit  his  active  membership 
in  the  AM.A  if  he  fails  to  pay  the  delinquent  dues 
within  30  days  after  the  notice  of  his  delinquency 
has  been  mailerl  by  the  Secretary  of  the  .AM.A  to  his 
last  known  address. 

12.  Members  of  the  .AM.A  who  have  been  dropped 
from  the  Membership  Roll  for  nonj)ayment  of  annual 


dues  cannot  be  reinstated  until  such  indebtedness 
has  been  discharged. 

13.  The  apportionment  of  delegates  from  each 
constituent  association  shall  be  one  delegate  for  each 
thousand  (1,000),  or  fraction  thereof,  active  members 
of  the  American  Medical  Association  as  recorded  in 
the  office  of  the  Secretary  of  the  American  Medical 
Association  on  December  1 of  each  year. 

CORRESPONDENCE 

Washington,  L).  C.,  December  18,  19.S1 
To  THE  Editor: 

In  connection  with  licensure  status  of  interns,  resi- 
dent and  assistant  resident  physicians  in  local  hospitals 
(except  those  governed  by  Section  42  of  the  Healing 
.Arts  Practice  .Act),  the  Commission  on  Licensure  at  a 
Special  Meeting  held  December  17,  1951  took  the  fol- 
lowing action: 

“LTpon  motion  duly  made,  seconded,  and  unani- 
mously passed  by  the  Commission  on  Licensure,  Healing 
.Arts  Practice  .Act,  it  is  resolved  that  interns,  assistant 
residents  and  resident  physicians  on  the  house  staffs 
of  all  local  hospitals,  except  those  governed  by  Section 
42  of  the  .Act  to  Regulate  the  Practice  of  the  Healing 
.Art  to  Protect  the  Public  Health  in  the  District  of 
Columbia  (Public  Law  831 — 70th  Congress),  are  not 
persons  engaged  in  or  practicing  the  healing  art  in  the 
District  of  Columbia  as  referred  to  in  Section  3 of  said 
.Act. 

“Pursuant  to  the  foregoing  and  to  enable  the  Com- 
mission to  properly  administer  the  .Act  of  Congress  above 
mentioned,  all  hospitals  within  the  District  of  Columbia 
having  under  their  jurisdictions  or  in  their  employ  any 
such  interns,  assistant  residents  and  resident  physicians 
are  hereby  required  to  furnish  the  Commission  in  writing 
the  name  of  each  intern,  assistant  resident  anil  resident; 
the  nature  of  the  course  he  is  pursuing  or  intends  to 
jiursue;  the  duration  thereof  as  required  by  the  Specialty 
Board  or  Licensure  Board  under  which  this  training  is 
being  jiursued  and  to  further  notify  the  Commission 
ujion  the  termination  of  such  [leriod. 

“If  for  any  reason  it  is  desired  to  extend  the  period 
of  training  beyond  that  reejuired  by  the  Sjiecialty  Board 
or  Licensure  Board,  jiroper  aj){)lication  for  determination 
shall  be  made  to  the  Commission  prior  to  the  expiration 
of  the  fieriod  of  training  referred  to  above.” 

Very  truly  yours, 

Daniei-  I..  Seckinger,  M.D.,  Dr.  P.H. 

Secretary-Treasurer,  Commission  on  Li- 
censure, District  of  Columbia 


The  1952  Scientific  Assembly  of  the  American 
Academy  of  General  Practice  will  be  held  in  Atlantic 
City,  N.  J.,  March  24-27.  The  Congress  of  Delegates 
will  assemble  earlier  for  pre-Assembly  meetings. 

The  Fifth  American  Congress  on  Obstetrics  and 
Gynecology  will  convene  in  Cincinnati,  Ohio,  March 
31  through  April  4,  1952,  at  the  Netherland  Plaza 
Hotel.  The  Congress  will  feature  a comprehensive 
five-day  scientific  program  covering  the  medical, 
nursing  and  public  health  aspects  of  the  maternal 
care  team.  Registration  fees  are  S5  for  members 
and  Sin  for  nonmembers.  Further  information  may 
be  secured  by  writing  to  Dr.  Donald  F.  Richardson, 
Executive  Secretary  of  the  sponsoring  organization, 
the  American  Committee  on  Maternal  Welfare,  116 
South  Michigan  Avenue,  Chicago  3,  Illinois. 

The  Second  National  Cancer  Conference  will  be 
held  at  the  Netherland  Plaza  Hotel  in  Cincinnati, 
Ohio,  March  3-5,  1952.  This  Conference  is  spon- 
sored jointly  by  the  American  Cancer  Society,  the 
National  Cancer  Institute  of  PHS,  and  the  Ameri- 
can Association  for  Cancer  Research.  A series  of 
panel  presentations  and  discussions  will  cover  the 
clinical  aspects  of  cancer  and  the  progress  of  present- 
day  research.  The  j^rogram  lists  speakers  of  prom- 
inence from  all  over  the  Fruited  States  together  with 
a sprinkling  of  foreign  names.  Included  in  the  list 
are  Dr.  Charles  F.  Ceschickter,  Washington,  and 
Drs.  Roy  Hertz  and  Thelma  B.  Dunn,  of  Bethesda, 
Md.  Dr.  Ceschickter  will  participate  in  a Panel  on 
Cancer  of  the  Breast;  Dr.  Hertz  will  discuss  steroid 
therapy  in  the  same  panel;  and  Dr.  Dunn  will  speak 
on  the  etiology  of  cancer  in  a Panel  on  Lymphoma 
and  Leukemia.  Dr.  Hertz  will  also  discuss  a jmper  on 
the  “Role  of  Steroids  in  Cervical  Cancer”  by  Dr. 
William  Lb  Gardner  of  New  Haven,  Conn. 


February  15-16 
March  13-14 
March  28 
.\pril  24-25 
.\pril  27-29 
May  2-3 


Birmingham,  .\labama;  Tutwiler  Hotel 
Pittsburgh,  Penna.;  William  Penn  Hotel 
Tulsa,  Okla.;  Mayo  Hotel 
Detroit,  Mich.;  Hotel  Statler 
Kansas  City,  Mo.;  President  Hotel 
Colorado  Springs,  Colo.;  Broadmoor  Hotel 


Surgical  papers  will  be  presented  and  panel  discus- 
sions led  by  outstanding  speakers,  all  nationally 
known  in  their  respective  fields,  at  each  of  the  re- 
gional meetings. 


The  American  College  of  Physicians  announces 
its  series  of  postgraduate  courses  for  the  spring  of 
1952.  They  are  scheduled  to  be  held  in  widely  sepa- 
rated cities,  but  many  of  them  will  be  accessible  to 
Washington  physicians.  A list  of  the  courses  follows : 

No.  1.  Gastroenterology,  February  25-29,  Stanford  Uni 
versity  School  of  Medicine  and  University  of  California  .Medi- 
cal School,  San  Francisco.  Dwight  L.  Wilbur.  M.D.,  and  Theo- 
dore L.  Althausen,  M.D.,  Co-Directors. 

No.  2.  Current  Concejits  of  .\llergy  and  Associated  Dis- 
orders, March  3-7,  Washington  University  School  of  Medicine, 

St.  Louis.  Harry  L.  .Mexander,  M.D.,  Director. 

No.  3.  Diseases  of  the  Blood  Vessels;  Diagnosis  and  Modern 
Treatment,  March  10-15,  Cornell  Lhiiversily  Medical  College 
and  The  New  York  Hospital,  New  York.  Irving  S.  Wright, 
M.D.,  Director. 

No.  4.  Clinical  Medicine  from  the  Hematologic  Viewpoint, 
March  17-22,  Ohio  State  Lhiiversity  College  of  Medicine,  ^ 
Columbus.  Charles  Doan,  M.D.,  Director.  ; 

No.  5.  Internal  Medicine,  .\[)ril  14-18,  University  of  Michi- 
gan Medical  School,  Ann  Arbor.  Cyrus  S.  Sturgis,  M.D.,  ; 

Director.  .| 

No.  6.  Electrocardiography:  Basic  Principles  and  Inter-  | 
pretation,  May  12-17,  Massachusetts  General  Hospital,  Bos-  j 
ton.  Conger  Williams,  M.D.,  Director.  ” 

No.  7.  Trends  and  Newer  Developments  in  Internal  Medi-  . 
cine.  May  12-16,  Hahnemann  Medical  College  of  Hosjrital  of 
Philadelphia,  Philadelphia.  Charles  L.  Brown,  M.D.,  Director. 

No.  8.  Physiological  Basis  for  Internal  Medicine,  June  2-7, 
University  of  Toronto  F’aculty  of  Medicine,  Toronto.  Ray  h'. 
Fartjuharson,  M.D.,  Director. 


Six  regional  meetings  of  the  United  States  Chap- 
ter of  the  International  College  of  Surgeons  have 
been  scheduled  for  the  early  months  of  1952.  They 
are: 


For  each  course  the  fees  per  week  to  members  of 
the  College  are  S30  and  to  nonmembers,  S60,  with 
the  exception  of  Course  No.  6,  for  which  the  fees 
are  S60  to  members  and  Si 20  to  nonmembers. 


114 


VOL.  XXI,  NO.  2 


Medical  Annals  of  the  District  of  Columbia 


115 


All  registrations  must  be  made  through  the  Ex- 
ecutive Offices  of  the  College,  E.  R.  Loveland,  Ex- 
ecutive Secretary,  4200  Pine  Street,  Philadelphia 
4,  Penna. 

The  Fifth  Annual  Postgraduate  Course  in  Dis- 
eases of  the  Chest,  sponsored  by  the  Council  on 
Postgraduate  Medical  Education  and  the  Pennsyl- 
vania Chapter  of  the  American  College  of  Chest 
Physicians  and  the  Laennec  Society  of  Philadelphia, 
will  be  presented  at  the  Warwick  Hotel,  Phila- 
delphia, March  24-28.  Physicians  interested  in  at- 
tending the  postgraduate  course  are  invited  to  com- 
municate with  the  Executive  Offices  of  the  College, 
112  East  Chestnut  Street,  Chicago  11,  111. 

George  Washington  University  School  of  Medi- 
cine announces  that  its  1952  Postgraduate  Program 
will  begin  on  I’ebruary  25  and  extend  through  March 
28.  As  in  the  past,  the  courses  will  be  full-time  and 
intensive,  with  instruction  from  9 a.m.  to  5 p.m. 
each  day,  Monday  through  Friday.  Tuition  is  S75.00 
per  week.  Three  courses  are  offered: 

Surgery,  February  25-29 

Obstetrics  and  Gynecology,  March  10-14 

General  Medicine,  March  24-28 

All  sessions  will  be  held  in  the  Conference  Room 
of  the  University  Hospital.  Inquiries  should  be  ad- 
dressed to  Dr.  Thomas  M.  Peery,  Director  of  Post- 
graduate Instruction,  901  23rd  Street,  N.W.,  Wash- 
ington 7,  D.  C. 

The  Kellogg  Lectures,  sponsored  by  George 
Washington  University,  will  be  held  during  the 
weeks  of  postgraduate  instruction.  These  meetings 
will  convene  in  Hall  A of  the  School  of  Medicine, 
1335  H Street,  X.W.,  at  8:30  p.m.  and  are  open  to 
the  medical  profession.  The  first  Lecture  is  scheduled 
for  February  28.  The  name  of  the  speaker  and  the 
subject  he  will  discuss  together  with  succeeding 
Lecture  topics  are  listed  in  the  Calendar  of  Medi- 
cal Meetings  appearing  in  this  issue  of  the  An- 
nals. 

The  District  of  Columbia  Dental  Society  extends 
a cordial  invitation  to  members  of  the  Medical 
Society  of  the  District  of  Columbia  to  attend  the 
20th  Annual  Postgraduate  Clinic  at  the  Shoreham 
Hotel,  March  9 to  12. 


Members  of  the  George  Washington  University 
Medical  Society  are  urged  to  attend  the  Society’s 
26th  Annual  Banquet  and  Alumni  Reunion  at  the 
Mayflower  Hotel,  February  16,  at  7 p.m.  Football 
Coach  “Bo”  Rowland,  as  he  is  affectionately  known, 
will  be  the  principal  speaker.  Dr.  Richard  H.  Fischer 
is  in  charge  of  banquet  reservations. 

The  Board  of  Directors  of  the  Washington  Home 
for  Foundlings  announces  that  it  is  now  authorized 
to  place  babies  for  adoption.  Physicians  are  cordially 
invited  to  make  inquiries  of  Miss  klvelyn  Hibbard, 
Director  of  the  Home,  Woodley  6367,  and  to  make 
a personal  visit  to  the  Home,  which  is  located  at 
4510  42nd  Street,  N.W. 

The  Washington  Home  for  Foundlings,  incorpo- 
rated by  an  Act  of  Congress  in  1870,  has  long  been 
distinguished  for  the  care  of  foundlings  and  babies 
of  unwed  mothers  of  all  creeds.  It  has  ample  facili- 
ties for  the  care  of  newborn  infants.  The  emotional 
as  well  as  the  physical  needs  of  the  infants  are  met 
by  individualized  care.  Medical  and  psychological 
studies  are  part  of  the  routine  care. 

Members  of  the  Medical  Society  serving  on  the 
Board  of  the  Home  are:  Drs.  William  S.  Anderson, 
who  is  also  Medical  Director,  and  Drs.  Lewis  C. 
Ecker,  Clarence  K.  Fraser,  Harry  H.  Kerr,  and 
Calvin  T.  Klopp.  Consultants  to  the  Medical 
Director  are  Drs.  Robert  E.  Moran,  William  J. 
Tobin  and  Wendell  M.  Willett. 

The  Board  feels  strongly  that  direct  placement  of 
infants  is  not  in  the  best  interests  of  either  the  child 
or  the  parents.  There  are  multiple  problems  which 
arise  in  connection  with  placing  babies  for  adoption 
which  only  authorized  child  placement  agencies  are 
in  a position  to  solve.  The  Board  hopes  that  phy- 
sicians will  acquaint  themselves  with  some  of  these 
problems  through  visits  to  the  Home  or  by  calling 
Miss  Hibbard. 

Officials  of  Providence  Hospital  are  announcing 
plans  for  financing  a new  350-bed  hospital.  A 
I)ublic  campaign  for  a million  dollar  subscription 
drive  was  launched  early  this  month.  Mr.  John  A. 
Reilly,  President  of  the  Second  National  Bank  and 
President  of  the  Hosjiital  .‘\dvisory  Board,  is 
directing  the  campaign. 


116 


Xews  and  Personals 


FEBRUARY,  1952 


The  new  hospital,  to  cost  approximately 
S7,()()(),()()0,  will  be  built  on  a 15-acre  tract  at  12th 
and  Varnum  Streets,  N.E.,  near  Catholic  Uni- 
versity. It  is  expected  that  half  the  cost  of  the 
institution  will  be  met  by  Federal  funds.  More  than 
S2, 500, 000  will  be  raised  from  outside  sources  by  the 
Sisters  of  Charity,  Emmitsburg  (Md.)  Province,  who 
organized  Providence  Hosj)ital  nearly  a century  ago. 

Xo  announcement  has  been  made  concerning 
the  disposition  of  the  property  at  2nd  and  D Streets, 
present  site  of  Providence. 

The  1051  building  fund  drive  of  Children’s 
Hospital  exceeded  its  goal  of  S545,000  by  S2,688. 
The  original  sum  of  $2,500,000  which  had  been 
raised  for  the  new  building  proved  inadequate  be- 
cause of  the  increased  cost  of  labor  and  building 
material,  and  a supplementary  drive  for  funds  was 
necessary.  Present  plans  call  for  occupancy  of  the 
new  building  by  September,  1052. 

The  first  issue  of  the  Journal  of  the  Student  Ameri- 
can Medical  Association,  which  made  its  appearance 
in  the  Medical  Society’s  offices  on  January  17,  re- 
flects the  enthusiasm  of  its  youthful  staff.  It  is  a 
creditable  journal  with  attractive  cover  and  format. 
This  first  issue  contains  three  scientific  articles,  one 
by  a guest  author.  Dr.  Robert  M.  Janes,  Head  of 
the  Department  of  Surgery  of  the  University  of 
Toronto,  and  the  two  others  by  medical  students. 

It  is  interesting  to  note  that  socio-economic  prob- 
lems will  occupy  a considerable  portion  of  the  jour- 
nal, five  articles  coming  under  this  classification. 
Dr.  Austin  Smith,  Editor  of  the  Journal  of  the  AM  A, 
has  written  the  guest  editorial. 

Members  of  the  editorial  staff,  Russell  F.  Stau- 
dacher,  E.xecutive  Editor,  Walter  H.  Kemp,  Man- 
aging Editor,  Philip  F.  Corso,  Student  Editor,  and 
Thomas  R.  (lardiner.  Advertising  Director,  are  to 
be  congratulated  on  this  new  addition  to  the  field 
of  semi-scientific  publications.  The  editorial  offices 
of  the  Journal  of  the  Student  AM  A are  located  at 
555  North  Dearborn  Street,  Chicago  10,  Illinois. 

The  Executive  Board  of  the  Medical  Society  of 
the  District  of  Columbia  at  its  regular  meeting,  De- 
cember 17,  approved  the  recommendation  of  the 
Committee  on  Public  Health  and  the  Subcommit- 
tee on  Child  Welfare  for  fluoridation  of  the  city’s 
water  supply. 


X"ew  officers  of  the  Prince  Georges  County 
Medical  Society  are  as  follows: 

Dr.  Samuel  J.  N.  Sugar,  President;  Dr.  John  M.  Warren, 
Vice  President;  Dr.  Benjamin  S.  Miller,  Corresponding  Secre- 
tary; Dr.  Julius  Kauffman,  Recording  Secretary;  Dr.  William 
B.  Hagan,  Treasurer. 

Members  of  the  Washington,  D.  C.  Section  of  the 
American  Congress  of  Physical  Medicine  inspected 
the  Physical  Therapy  Clinic  of  Walter  Reed  Army 
Hospital,  January  9,  at  the  invitation  of  Lt.  Colonel 
J.  H.  Kuitert,  M.C.,  Chief  of  the  Physical  Medicine 
Service.  Following  the  breakfast  meeting  and  in- 
spection of  the  Clinic  a motion  picture  on  “Rheu- 
matoid Arthritis  of  the  Spine”  was  shown. 

The  Research  Foundation  of  Doctors  Hospital 
has  received  a donation  in  memory  of  the  late 
Dr.  Leon  S.  Gordon  from  the  physician’s  mother, 
Mrs.  Freda  Gordon,  and  two  brothers,  Drs.  Everett 
J.  and  David  S.  Gordon.  The  gift  will  make  it 
possible  for  the  Foundation  to  award  an  annual 
prize  to  one  of  its  outstanding  resident  physicians. 
The  donation  was  presented  by  Dr.  Leon  Gordon’s 
daughter,  Susan,  11  years  of  age,  who  was  born  in 
Doctors  Hospital  on  Christmas  Day  in  1940,  the 
first  year  of  the  Hospital’s  operation.  Dr.  Charles 
Stanley  White,  President  of  the  institution,  ac- 
cepted the  gift. 

Dr.  Russell  J.  Fields  addressed  the  Medical  , 
Arts  Society,  Februarj"  14,  at  the  Kennedy  Warren. 
His  subject  was  “What’s  X"ew  in  Dermatologj'.”  j 

The  Section  on  General  Practice  met  in  the  j 
Medical  Society’s  Library,  January  22.  The  principal 
speaker  was  Dr.  Hugh  H.  Hussey,  Editor  of  G.  P. 
and  Associate  Professor  of  Medicine,  Georgetown 
University  School  of  Medicine,  who  spoke  on 
“Medical  Reading  and  Writing.” 

I 

The  Section  on  Neurology  and  Psychiatry  elected  ; 
new  officers,  January  5.  They  are: 

Dr.  J.  Peter  Murphy,  Chairman;  Dr.  Leon  Saizman,  Vice 
Chairman;  Dr.  Harvey  H.  .\mmerman,  Secretary-Treasurer. 

The  Women’s  Medical  Society  held  a joint 
meeting  with  the  1).  C.  Women’s  Bar  .\ssociation  on 
February  5 in  the  Medical  Society’s  auditorium. 
Judge  X’^adine  Lane  Gallagher  addressed  the  joint 


VOL.  XXI,  NO.  2 


Medical  Annals  of  the  District  of  Columbia 


117 


meeting  on  “The  Respon- 
sibilities of  the  Profes- 
sional Women.” 

Dr.  John  Minor  was 
host  to  the  Clinico-Patho- 
logical  Society,  January 
15.  Dr.  Worth  B.  Daniels 
presented  a paper  on  “The 
Diagnosis  and  i^anage- 
fnent  of  Pyogenic  Menin- 
gitis.” 


I 

i 


I 

I 

I 

I 

I 

t' 

I 

I , 

t 


I 


I 

I 


Washington  Post  Photo 

DR.  OVERHOLSER  HONORED  BY  FRENCH  GOVERNMENT 

Dr.  Winfred  Overholser,  Superintendent  of  St.  Elizabeths  Hospital,  receives 
medal  of  the  French  Legion  of  Honor  from  Dr.  Yves  Porc’her  (right).  The 
French  Government  was  represented  at  the  ceremonies  by  its  Consul  in  Washing- 
ton, Pierre  Dupont. 


The  District  of  Colum- 
bia Commissioners,  under 
an  order  issued,  December 
27,  authorized  the  assign- 
ment of  chest  surgeons 
from  Walter  Reed  Army 
Hospital  to  periodic  surgi- 
cal duty  at  Glenn  Dale 
Sanatorium.  This  new  pro- 
cedure will  furnish  Walter 
Reed  Hospital,  which  has 
an  excellent  chest  surgery  service,  with  a sufficient 
number  of  tuberculosis  cases  to  get  it  approved 
for  a residency  training  program.  The  Army  will 
supply  its  own  anesthetists. 

Dr.  John  P.  McGovern,  Chief  of  the  Outpatient 
Department  at  Children’s  Hospital,  and  Assistant 
Professor  of  Pediatrics  at  George  Washington 
University  School  of  Medicine,  was  elected  a \lce 
President  of  the  Walter  Reed  Society,  a new'  or- 
ganization which  was  founded  in  Los  Angeles  early  in 
December  at  the  close  of  the  meetings  of  the  AMA. 

The  Society,  which  is  sponsored  by  the  National 
Society  for  Medical  Research,  is  comprised  of  those 
who  have  served  as  “human  guinea  pigs”  in  medical 
research  or  experimentation  under  the  direction  of 
a qualified  scientist.  It  is  named  in  honor  of  Dr. 
Walter  Reed,  who  risked  his  life  in  the  fight  against 
yellow'  fever  and  w'ho  first  dramatized  the  use  of  the 
human  volunteer  in  experimental  medicine. 

Dr.  Max  Sadove,  Head  of  the  Department  of 
Anesthesiology  of  the  University  of  Illinois,  was 
elected  organizing  President. 

Dr.  Winfred  Overholser,  Superintendent  of  St. 
Elizabeths  Hospital,  was  awarded  the  French 


Legion  of  Honor  Medal,  December  27,  making  him 
a knight  of  the  Legion  of  Honor.  The  ceremonies 
took  place  in  Dr.  Overholser’s  home  on  the  Hospital 
grounds.  Dr.  Yves  Porc’her,  a psychiatrist  and  a 
hero  of  the  French  resistance  movement  during 
World  War  H,  presented  the  medal  to  Dr.  Over- 
holser. Pierre  Dupont,  French  Consul,  represented 
the  French  Government  at  the  ceremonies. 

Dr.  Overholser,  who  was  one  of  six  persons  who 
were  voted  to  receive  the  medal  last  July  at  the 
International  Congress  of  Psychiatry  in  Paris,  worked 
with  French  civilians  while  serving  with  the  U.  S. 
Army  during  World  War  1.  He  was  Chairman  of 
the  United  States  delegation  to  the  International 
Congress  on  Mental  Health  in  1948  and  toured 
Fiuropean  countries  to  study  mental  health  prob- 
lems. The  medal  was  aw'arded  to  him  because  of  his 
world-wide  interest  in  psychiatry.  Mr.  Dupont 
added  that  it  was  also  intended  to  honor  the  Ameri- 
can jieople  for  their  friendship  to  the  French. 

President  of  the  Medical  Society,  Dr.  Frank  D. 
Costenbader,  was  a member  of  the  Sjiecial  Gifts 
(’ommittee  for  The  March  of  Dimes,  the  annual 
campaign  for  funds  for  the  National  Foundation  for 
Infantile  Paralysis,  Inc.  The  money  collected  is 


t 


I 


118 


Xews  and  Personals 


FEBRUARY,  1952 


used  not  only  for  treatment  but  for  research  aimed 
at  prevention  of  the  disease. 

Dr.  Brian  B.  Blades,  Professor  of  Surgery, 
George  Washington  University  School  of  Medicine, 
was  elected  Secretary  of  the  Spiecial  Medical  Ad- 
visory Group)  of  the  Veterans  Administration, 
effective  January  1.  Dr.  Derrick  T.  Uail,  of  North- 
western University,  was  named  Chairman  of  the 
Group,  succeeding  Dr.  Charles  W.  Mayo,  of  the 
Mayo  Clinic,  Rochester,  who  has  served  as  Chair- 
man since  the  Group  was  organized  si.x  years  ago. 
Dr.  Mayo  will  continue  as  a member  of  the  Group. 

The  Special  Medical  Advisory  Group  is  com- 
posed of  20  members,  all  nationally  known  in  the 
field  of  medicine,  nursing,  and  social  sciences.  They 
constitute  the  top  medical  advisory  group  in  VA 
under  the  provisions  of  the  law  that  provided  for  the 
creation  of  VA’s  Dep)artment  of  Medicine  and 
Surgery  in  1945.  They" serve  in  an  advisory  capacity 
in  the  establishment  of  policies  for  the  Department 
of  Medicine  and  Surgery. 

Another  Washington  member  of  the  Advisory 
Group)  is  Dr.  Arthur  C.  Christie. 

Dr.  Irvin  Hantman  presented  a paper  on  “Secre- 
tory Otitis  Media”  before  the  Ear,  Nose  and  Throat 
Section  of  the  New  York  .Academy  of  Medicine  in 
New  York  City,  November  19. 

Dr.  Harold  Jeghers,  Professor  of  Medicine, 
Georgetown  University  School  of  Medicine,  was  in 
Buffalo,  New  York,  November  6 to  9,  where  he 
visited  Mercy  Hosp)ital  in  connection  with  the 
teaching  program  which  has  been  established  be- 
tween this  hosp)ital  and  Georgetown.  On  November 
9 he  lectured  before  the  regional  meeting  of  the 
Catholic  Hospital  Association  on  the  subject, 
“Improving  the  Educational  Program  in  the 
Hosp)ital.” 

During  the  last  week  in  October  Dr.  Jeghers 
attended  the  1951  meeting  of  the  .Association  of 
■American  Medical  Colleges  in  French  Lick,  Indiana. 

Dr.  A.  Harry  Ostrow,  Director  of  Dental  Serv- 
ices, District  Health  Dep)artment,  was  one  of 
seven  alumni  honored  l)y  Central  High  School 
Alumni  Association  at  its  44th  annual  reunion  in 
the  Shoreham  Hotel,  December  27.  Dr.  Ostrow,  of 


the  Class  of  1921,  was  recognized  as  a pioneer  in  the 
water  fluoridation  pjrogram  of  the  District  of 
Columbia.  He  has  written  an  editorial  on  the 
subject  of  water  fluoridation  which  appears  in  this 
issue  of  the  Medical  Annals. 

Dr.  John  J.  Curry,  Assistant  Professor  of  Medi- 
cine at  Georgetown  University  School  of  Medicine, 
addressed  a meeting  of  the  Montgomery  County 
Medical  Society,  January  15,  in  Olney  Inn,  Olney, 
Md.  Dr.  Curry’s  papier  was  entitled,  “The  Evalu- 
ation of  Shortness  of  Breath.” 

Dr.  Russell  L.  Haden,  Medical  Director  of  the 
■American  Red  Cross  blood  program,  has  been 
apipointed  Chairman  of  the  program’s  Committee  on 
Medical  Policies  and  Procedures.  In  this  capacity 
Dr.  Haden  succeeds  Dr.  Ross  T.  MeIntire,  who 
retired  as  Committee  Chairman  last  November  but 
continues  to  serve  as  a member  of  the  Committee  in 
a volunteer  capacity. 

Captain  Joseph  W.  Watson,  internist  at  the 
382nd  General  Hospital  near  Osaka,  Japan,  was  a 
recent  participiant  in  a Symposium  on  Epidemic 
Hemorrhagic  Fev^er  held  at  the  Tokyo  .Army  Hos- 
piital.  His  topic  was  “Sequela  of  Ep)idemic  Hemor- 
rhagic Fever  in  the  Convalescent  Phase.” 

Captain  \\’atson  was  recalled  to  active  duty  with 
the  382nd  General  Hosp)ital  early  in  1951. 

Dr.  Frederick  B.  Brandt  is  a diplomate  of  the 
■American  Board  of  Surgery,  having  been  certified  by 
the  Board  in  December,  1951. 

Several  removals  from  \\'ashington  of  Medical 
Society  members  have  been  rep)orted; 

Dr.  Benjamin  F.  Miller,  who  has  been  living  in 
Boston  for  some  time  piast,  has  decided  to  remain 
there.  His  address  is  217  Kent  Street,  Brookline 
46,  Mass. 

Dr.  William  H.  Woodson  is  practicing  his 
specialty,  orthop)edic  surgery,  in  Twin  Falls,  Idaho. 
His  office  is  located  in  the  Medical  .Arts  Building, 
106  Locust  Street  North. 

Dr.  Kaden  Tierney  has  moved  his  office  and 
practice  to  Milford,  Delaware. 

Major  Theresa  T.  Woo  is  piresently  stationed 
at  the  LL  S.  .Army  Hospital  in  Fort  Belvoir,  Ya. 


MEMBERSHIP 


The  following  applicants  for  membership  were 
duly  elected  to  membership  at  the  meeting  of  the 
Executive  Board,  December  17,  1951,  in  accord  with 
Amendment  XI,  Section  2,  of  the  Constitution  and 
By-laws  of  the  Society. 

Active  Members 

Harvey  H.  Ammerman,  1612  Rhode  Island  Avenue,  NAV. 
James  Esten  Abel,  4536  3rd  Street,  S.E. 

James  B.  Bain,  1712  Rhode  Island  Avenue,  N.W. 

David  F.  Bell,  Jr.,  1150  Connecticut  Avenue,  N.W. 

Theodore  Bisland,  Gallinger  Municipal  Hospital 
Henry  F.  Capozzella,  4127  River  Road,  N.W. 

Herbert  Cohen,  1728  Massachusetts  Avenue,  N.W. 

Robert  Day,  2000  Massachusetts  Avenue,  N.W. 

Russell  B.  Diley,  819  Carroll  Avenue,  Takoma  Park,  Md. 
Sanford  H.  Eisenberg,  1918  K Street,  N.W. 

Leon  Ferber,  2025  Eye  Street,  N.W. 

Frank  A.  Finnerty,  Jr.,  Marshall  Drive,  RFD  2,  Fairfax,  Va. 
Robert  J.  Furie,  4520  MacArthur  Boulevard,  N.W. 

Jason  Geiger,  3200  16th  Street,  N.W. 

Seymour  Greenbaum,  9300  Ewing  Drive,  Bethesda,  Md. 
Edwin  S.  Kessler,  1464  Columbia  Road,  N.W. 

Van  Wyke  Gunter,  2110  Dennis  Avenue,  Silver  Spring,  Md. 
John  P.  Haberlin,  1907  Eye  Street,  N.W. 

Charles  W.  Humphreys,  Jr.,  4508  38th  Street,  N.W. 

Harold  B.  Lehrman,  1728  Massachusetts  Avenue,  N.W. 

Leon  McNeely  Liverett,  1801  K Street,  N.W. 

Joseph  C.  McCarthy,  5229  11th  Street,  South,  Arlington,  Va. 
John  R.  O’Brien,  7314  Bradley  Boulevard,  Bethesda,  Md. 
Louis  Schwartz,  915  19th  Street,  N.W. 

Robert  W.  Sjogren,  1835  Eye  Street,  N.W. 

Herbert  Wanderman,  1723  M Street,  N.W. 

Herbert  M.  Wechsler,  900  17th  Street,  N.W. 

Frank  B.  Whitesell,  Jr.,  3000  Connecticut  Avenue,  N.W. 

Associate  Members 

Robert  H.  Anderson,  3523  Valley  Drive,  Alexandria,  Va. 

John  Lawrence  Avery,  1611  Monroe  Street,  N.W. 

Louis  L.  Cross,  Jr.,  1319  Maple  View  Place,  S.E. 

James  Burnett  Gilbert,  507  South  Lee  Street,  Alexandria,  Va. 
Alexander  Goulard,  Jr.,  1809  24th  Street,  N.VV\ 

Efrain  Guerrero  Z,  2125  Le  Roy  Place,  N.W. 

Thomas  E.  Mattingly,  Jr.,  2710  Upshur  Street,  Mt.  Rainier, 
Md. 

Seward  E.  Miller,  4513  Saul  Road,  Kensington,  Md. 

F.  E.  Musser,  7409  Varnum  Street,  Landover  Hills,  Md. 
George  Peter  Petropoulos,  1228  11th  Street,  N.W. 

John  R.  Portaria,  113  Carroll  Street,  Takoma  Park,  Md. 
Jackson  A.  Saxon,  7806  Garland  Avenue,  Takoma  Park,  Md. 
Hans  Frank  Smetana,  5521  Hoover  Street,  Bethesda,  Md. 
Irene  G.  Tamagna,  6501  Connecticut  Avenue,  N.W. 

Russell  McF.  Tilley,  3900  Hamilton  Street,  Hyattsville,  Md. 

Affiliate  Member 

Robert  L.  Norment,  1801  Eye  Street,  N.W. 


Resident-Intern  Member 

Peter  Soyster,  1911  Howard  Court,  Falls  Church,  Va. 

Recent  changes  in  membership  status: 

Active  to  Associate 

John  M.  Baber  Hubert  B.  Haywood,  Jr. 

James  N.  Greear  Henry  R.  Lyons 

Blaine  H.  Eig  Edward  C.  Morse 

Hyman  J.  Zimmerman 

Affiliate  to  Associate 
Joseph  W.  Stein 

Resigned 

Active 

Francis  A.  Barrett  Elizabeth  B.  Goldsworthy 

Harold  L.  Dyer  Edward  B.  McCabe 

Associate 

Robert  L.  Roy 
Joseph  J.  Tamasi 
William  E.  Torrey 

Affiliate 

John  A.  Norcross 

Resident-Intern 
Dan  B.  Greer 

Five  New  Life  Members 

Chapter  II,  Article  IV,  of  the  Constitution  of  the 
Society,  reads  as  follows: 

Life  members  shall  be  active  members  who  have  been 
active  members  for  a total  of  forty  years.  They  shall  have  all 
of  the  privileges  of  active  membership  and  shall  be  exempt 
from  paying  dues  and  assessments. 

Our  honor  roll  now  numbers  77.  The  congratula- 
tions of  the  Society  are  extended  to: 


Seniority 

umber 

,547 

Joseph  B.  Bogan 

Date  of 

M ember  ship 

February  9,  1911 

553 

Lewis  C.  Ecker 

April  25,  1911 

,555 

Harry  A.  Ong 

May  17,  1911 

557 

William  J.  Mallory 

May  24,  1911 

562 

John  W.  Burke 

October  5,  191 1 

who  have  for  forty  years  been  on  the  roster,  meeting 
all  dues  and  assessments  and  lending  their  support 
to  the  Society  by  frequent  attendance.  Their  status 
IS  now  elevated  to  Life  membershij). 


119 


OSCAR  BENWOOD  HUNTER,  M.D. 


OSCAR  BENWOOD  HUNTER,  A.B.,  A.M.,  M.D.,  F.A.C.P. 

(1888-1951) 


It  seems  only  yesterday  that  I was  talking  over 
a professional  problem  with  Dr.  Oscar  Benwood 
Hunter.  He  was  attacking  the  problem  from  all 
angles,  as  always,  in  search  of  an  answer.  That  day, 
Wednesday,  December  19,  1951,  was  a typical  day 
in  the  life  of  this  tireless  and  dynamic  man,  but  its 
closing  hours  brought  to  a sudden  end  two-score 
years  of  work  on  behalf  of  humanity,  his  chosen 
profession,  and  countless  civic  activities.  For  Dr. 
Hunter  such  a program  on  the  day  of  his  death  was 
quite  normal,  the  sort  of  program  he  would  have 
planned  if  given  a choice. 

Oscar  Hunter  was  indefatigable  in  his  fight  to 
maintain  the  rights  and  traditions  of  the  medical 
profession.  I have  heard  him  say  many  times,  “The 
doctor  today  must  be  both  a doctor  and  a politician.” 
This  axiom  typified  his  knack  of  mixing  the  practical 
with  the  human.  He  liked  people  but  he  did  not  stop 
there.  Rather  he  devoted  his  tireless  energy,  night 
and  day,  to  organizing  them  into  forces  for  good. 
For  many  years  he  let  the  human  side  dominate  his 
career.  The  ink  was  barely  dry  on  his  George  Wash- 
ington University  Medical  School  diploma  when  he 
first  stood  in  front  of  a class  as  instructor  in  anatomy. 
That  was  in  1912.  A year  later  he  was  a full  professor 
at  the  school,  continuing  his  pedagogical  career 
through  two  decades. 

Even  while  teaching  full-time.  Dr.  Hunter  took 
part  in  outside  activities.  A natural  organizer,  he 
was  soon  a leading  figure  in  a dozen  corollary 
fields.  In  spare  time  he  acquired  A.B.  and  A.M. 
degrees,  four  and  five  years,  respectively,  after  re- 
ceiving his  medical  degree.  Those  formative  years 
in  his  professional  career  were  marked  by  intense 
work  and  study,  particularly  in  pathology  and  bac- 
teriology. They  were  years  of  churning  activity,  a 
pace  that  he  always  maintained. 

Dr.  Hunter’s  practical  side  inevitably  led  him  two 
decades  ago  from  pedagogy  to  private  practice.  A 
born  teacher,  he  had  already  spent  twenty  years 
showing  others  how  to  {)ractice  the  medical  arts. 

In  the  process  he  frequently  served  as  consultant,  a 
role  he  loved.  With  only  a look  at  the  patient  and  a 
j glance  in  the  microscope  his  diagnostic  acumen  per- 
mitted early  impressions  that  were  usually  confirmed 
by  further  clinical  study. 

I 

I 121 


Believing  that  in  organization  there  is  strength. 
Dr.  Hunter  held  a deep  conviction  that  a committee 
assignment  or  official  role  imposed  an  obligation  to 
serve  to  the  best  of  his  ability.  A mere  listing  of  his 
official  capacities  would  more  than  fill  these  columns. 
Suffice  it  to  say,  he  always  managed  to  find  time  and 
energy  to  carry  forward  the  causes  in  which  he  be- 
lieved. 

There  are  more  than  a dozen  presidencies  of  im- 
portant organizations,  honors  he  earned  and  cher- 
ished. Among  these  were;  The  Medical  Society  of 
the  District  of  Columbia  (President  1928);  Southern 
Medical  Association  (President  1948-49);  American 
Therapeutic  Society  (President  1938-39  and  Secre- 
tary 1934-38  and  since  1939);  Washington  Society 
of  Pathologists  (President  1937-38);  The  George 
Washington  University  Medical  Society  (President 
1918-19  and  1938-39  and  Secretary  since  1939); 
and  General  Alumni  Association  of  the  George  Wash- 
ington University  (President  1928-29  and  1929-30). 
In  his  last  months  he  devoted  many  hours  to  the 
V'ice-Presidency  of  the  American  Medical  Associa- 
tion. Hardly  a fortnight  before  his  death  he  flew  to 
the  West  Coast  to  take  part  in  the  interim  meeting 
of  the  Association.  His  active  affiliations  in  recent 
years  included  twenty-five  important  professional 
societies  besides  as  many  semi-professional  and  civic 
organizations. 

Nationally  famed  as  a pathologist,  he  was  a mem- 
ber of  the  College  of  American  Pathologists,  a Fel- 
low of  the  American  College  of  Physicians,  and  a 
diplomate  of  the  American  Board  of  Pathology.  He 
had  contributed  more  than  fifty  articles  to  medical 
journals. 

His  many  professional  achievements  include  the 
develo{)ment  of  a laboratory  with  a staff  of  more 
than  thirty.  He  was  constantly  driving  and  building. 
One  of  the  active  organizers  of  the  Medical  Center 
in  Washington,  Dr.  Hunter  personally  encouraged 
the  sale  of  the  cai)ital  stock  of  Doctors  Hospital  to 
his  professional  colleagues,  in  whom,  he  thought, 
should  rest  the  destiny  of  this  venture.  He  served 
as  active  Secretary  of  the  four  operating  corjwra- 
tions. 

His  multifarious  activities  included  a directorship 
of  the  .Xmerican  .'\utomobile  .Association;  member- 


I 


I 


122 


Medical  Annals  of  the  District  of  Columbia 


FEBRUARY,  1952 


ship  in  the  Navy  League;  trustee  of  (Jroup  Hos- 
])italization,  Inc.,  which  he  helped  organize;  and 
Major  (inactive)  in  the  Army  Medical  Reserve 
Corps.  He  was  a member  of  the  University  Club, 
Kiwanis  Club  (President  1941),  Cosmos  Club,  Inter- 
national Medical  Club  (President  1951),  and 
Corinthian  Yacht  Club.  His  yacht  Decoy  was  burned 
during  World  War  H while  flying  the  Coast  Guard 
flag. 

Supported  by  a loyal  and  devoted  family.  Dr. 
Hunter  was  a gracious  host  to  his  many  friends  and 
his  hospitality  was  unlimited.  Much  of  the  story  of 
Oscar  Hunter,  the  man,  will  never  be  told,  simply 
because  he  did  not  choose  to  publicize  a side  of  his 
life  familiar  only  to  his  family  and  to  the  benficiaries 
of  his  boundless  generosity  and  sympathy  for  hu- 
manity. For  years  he  lent  a helping  hand  to  many 
medical  students  and  striving  young  physicians.  He 
gave  time  and  money  to  the  Kiwanis’  efforts  on 
behalf  of  crippled  children. 

Dr.  Hunter  nearly  qualified  as  a native  Washing- 
tonian, having  been  born  in  neighboring  Cherrydale, 
Virginia,  January  31,  1888.  He  married  Sidney  So- 
phia Pearson,  December  26,  1914.  Mrs.  Hunter  and 
four  children  survive  him:  Dr.  Oscar  Benwood  Hun- 
ter, Jr.,  Mrs.  Richard  H.  Fischer,  Miss  Mary  Ellen 
Hunter,  and  Mrs.  William  M.  Simpich. 

.'\s  I look  back  on  the  career  of  Dr.  Oscar  Benwood 
Hunter  I see  him  in  his  familiar  pose — hands  clasped 
above  his  head — his  way  of  acknowledging  {)ublic 
greetings.  This  was  his  symbol  of  success,  unity, 
brotherhood  and  good  will. 

.Arnold  McNitt,  M.D. 

Sympathomimetic  Amines — Lands  and  Tainter 

(Continued  from  page  68) 

7.  Erl.4NGER,  J.,  Gessell,  R.,  Gasser,  H.  S.,  and  Elliot, 

B.  L.:  J.  A.  M.  A.,  1917,  69,  2089. 

8.  Ebert,  R.  V.,  Hagen,  F.  S.,  and  Borden,  C.  VV.:  Sur- 

gery, 1949,  25,  399. 

9.  Remington,  J.  VV.,  and  others:  .Vm.  J.  Physiol.,  1950, 

161,  116. 

10.  Remington,  J.  VV.,  and  others:  Ibid.,  1950,  161,  106. 

11.  Remington,  J.  VV.,  and  others:  Ibid.,  1950,  161,  125. 

12.  P'reeman,  N.  E.,  Shaffer,  S.  A.,  Schecter,  E.,  and 

Rolling,  H.  E.:  J.  Clin.  Investigation,  1938,  17,  359. 

13.  Fine,  J.,  Seligman,  .\.  M.,  and  P'rank,  H.  .\.:  .Ann. 

Surg.,  1947,  126,  1002. 

14.  Remington,  J.  VV’.,  Wheeler,  N.  C.,  Boyd,  G.  H.,  Jr., 

AND  Caddell,  H.  M.:  Proc.  Soc.  Pixper.  Biol.  & Med., 
1948,  69,  LSO. 

15.  VViggers,  H.  C.,  Ingraham,  R.  C.,  Roemhild,  P’.,  and 

Goldberg,  H.:  .Am.  J.  Physiol.,  1948,  153,  511. 


16.  Lee,  R.  E.,  and  Zweifach,  B.  VV.:  Ibid.,  1949,  157,  259. 

17.  Lord,  J.  VV.,  Jr.,  and  Hinton,  J.  VV.:  New  England  J. 

Med.,  1947,  237,  840. 

18.  Phillips,  O.  C.,  and  Nicholson,  M.  J.:  S.  Clin.  North 

-America,  1950,  30,  705. 

19.  Rapport,  D.:  Am.  J.  Physiol.,  1922,  60,  461. 

20.  Driessens,  j.:  Rev.  de  chir.,  Paris,  1948,  67,  129. 

21.  Cannon,  VV’.  B.:  The  Wisdom  of  the  Body.  New  York: 

Norton,  1932. 

22.  Cohn,  R.,  and  Parsons,  H.:  .Am.  J.  Physiol.,  1950,  160, 

437. 

23.  Frank,  H.  .A.,  Seligman,  .A.  M.,  and  P'ine,  J.:  J.  Clin. 

Investigation,  1926,  25,  22. 

24.  Glasser,  O.,  and  Page,  I.  H.:  .Am.  J.  Physiol.,  1948, 

154,  297. 

25.  Lorhan,  P.  H.,  and  Lalich,  J.  J.:  .Anesth.  & .Analg., 

1940,  19,  66. 

26.  Weinstein,  M.,  and  Barron,  .A.:  .Am.  J.  Surg.,  1936, 

31,  154. 

27.  Lorhan,  P.  H.,  and  Mosser,  D.:  .Ann.  Surg.,  1947,  125, 

171. 

28.  King,  B.  D.,  and  Dripps,  R.  D.:  Surg.,  Gynec.  & Obst., 

1950,  90,  659. 

29.  .Altschule,  M.  D.,  and  Gilman,  S.:  New  England  J. 

Med.,  1939,  221,  600. 

30.  Wilson,  C.  M.,  and  Bassett,  R.  C.:  Univ.  Michigan  M. 

Bull.,  1950,  16,  57. 

31.  Deterling,  R.  .a.,  and  .Apgar,  W:  .Ann.  Surg.,  1951, 

133,  37. 

32.  Goldenberg,  M.:  .Am.  J.  Med.,  1951,  10,  627. 

33.  Pantridge,  j.  P'.,  and  Burrows,  M.  M.:  Brit.  M.  J , 

1951,  1,  448. 

34.  Goetz,  F.  C.,  editor:  .Am.  Pract.  & Digest  Treat.,  1951, 

2,  620. 

35.  Luger,  N.  M.,  Kleiman,  .A.,  and  P'reemont,  R.  E : 

J.  .A.  M.  .A.,  1951,  146,  1.592. 

. .Our  Greatest  Bulwark. . — Observer 

(Continued  from  page  103) 

tinuously  in  an  effort  to  broaden  their  coverage 
and  at  the  same  time  avoid  miscalculations  which 
would  result  in  financial  difficulties. 

One  has  the  uncomfortable  feeling  that  too 
many  doctors  are  unaware  of  this  situation  and, 
if  they  are,  they  are  lulled  into  the  belief  that 
whatever  happens  they  will  not  personally  be 
affected.  Nothing  could  be  further  from  the 
truth.  If  Blue  Shield  plans  fail  for  the  lack  of 
medical  support.  Government  intervention  is  in- 
evitable. Blue  Shield  and  all  other  prepayment 
plans  sponsored  by  medical  organizations  must 
be  made  to  work.  There  is  no  alternative  if  the 
doctors  wish  to  control  their  own  destiny. 

T.  W. 


MEDICAL  ANNALS 

of  the 

DISTRICT  OF  COLUMBIA 


VOLUME  XXI  March,  1952  NUMBER  3 


CONGENITAL  OBSTRUCTION  OF  THE  URINARY 
TRACT* 

MEREDITH  CAMPBELL,  M.D. 

Professor  of  Urology,  New  York  University  Post  Graduate 
Medical  School 


RINARY  obstruction  and  infection 
account  for  nine  tenths  of  the  major  urologic 
problems  in  infants  and  children.  Most  of  these 
obstructions  are  consequent  to  congenital  uri- 
nary tract  malformations,  many  of  the  anomalies 
being  actively  obstructive  while  others  are  po- 
tentially so.  It  is  axiomatic  that  the  urinary 
stasis,  whether  due  to  obstruction  or  other  cause, 
predisposes  to  the  advent  of  infection  and  that 
once  established  the  infection  is  unlikely  to  be 
cured  until  the  stasis-producing  condition  or  con- 
ditions are  eradicated. 

Irrespective  of  infection,  the  constant  impor- 
tant end  result  of  urinary  blockage  is  hydrone- 
phrosis with  its  accompanying  renal  injury  which 
may  be  unilateral  or  bilateral  according  to  its 
etiology.  Ureteral,  vesical  and/or  urethral  dilata- 
tion occurs  proximal  to  the  blockage  and  cor- 
relative to  the  location  and  severity  of  the  ob- 
struction. The  causes  of  hydronephrosis  in 
infants  and  children  are  given  in  table  1.  This 
shows  the  wide  variety  of  potential  obstructive 
lesions  to  which  these  young  patients  may  be 


* Address  delivered  before  the  Twenty-second  .Annual 
Scientific  Assembly  of  the  Medical  Society  of  the  District  of 
Columbia,  October  3,  1951. 


heir;  it  will  be  noted  that  the  majority  of  the 
more  important  conditions  are  congenital.  Be- 
tween 4 and  5 per  cent  of  all  children  are  born 
with  some  kind  of  urinary  obstruction;  in  many 
the  lesion  is  only  a tight  external  urethral  meatus, 
but  even  this  condition  is  of  great  potential 
obstructive  import.  In  nearly  every  case  the 
nature  of  the  obstructing  lesion  can  be  deter- 
mined by  adequate  urologic  examination  (table  2) . 

Symptoms 

The  symptoms  of  urinary  obstruction  are  local 
and  systemic.  The  local  manifestations  are  con- 
cerned with  pain  or  renal  tenderness  in  hydro- 
nephrosis or  ureteral  obstruction,  for  example, 
or  urinary  frequency  or  difficulty  in  lower  tract 
blockage  as  in  contracted  bladder  neck,  urethral 
stricture,  and  so  forth.  Sometimes  the  hydro- 
nephrotic  kidney,  the  chronically  distended  blad- 
der, or  a urethral  diverticulum  presents  a 
palpable  mass,  perhaps  even  first  detected  by  the 
child.  Hematuria,  acute  or  chronic  comj)lete  vesi- 
cal retention,  dribbling,  dysuria,  or  even  “enure- 
sis” may  reflect  the  obstruction.  Most  of  these 
children  are  urologically  examined  because  of 
persistent  gross  pyuria. 

The  systemic  symptoms  are  consequent  to 


123 


124 


MARCH,  1952 


Congenital  Ohstniction  of  Urinary  Tract — Campbell 


TABLE  1 


Causes  of  Hydronephrosis 
Congenital  Congenital  or  Acquired 

Pelvis  and  Kidney 

Renal  anomalies  of  number,  Abnormal  ureteral  insertion 
form,  location,  size,  Stricture  at  pelvic  outlet 

etc. 

■Accessory  renal  vessels 


.Anomalies  of  number 
.Anomalies  of  termination 
Valves  and  folds 
Ureterocele 
Avascular  blockage 

1.  Primary 

2.  Secondary 
Torsion 


Ureter 

Stricture 

Stenosis 

.Atony 

Spasm 

Cystic  dilatation 
Kinks 

■Angulations 

Diverticulum 


Bladder 


.Anomalies:  Exstrophy,  redu- 
jjlicated,  bipar- 
tite, etc. 

Trigonal  curtain  obstruction 

L’reterocele 

Hydrocolpos 


Contracture  of  vesical  neck 
Hypertrophy  of  vesical  neck 
Median  bar 

Hypertrophy  of  interureteric 
ridge 

Diverticulum 
Neuromuscular  disease 

1.  Cord  bladder 

2.  .Atonic  bladder 


Posterior  urethral  valves 
Penile  torsion 
.Abnormal  openings 

1.  Epispadias 

2.  Hypospadias 


Urethra 

Phimosis 
Meatus  stenosis 
Meatus  atresia 
Stricture 
Cysts 

Diverticulum 
Hypert  rophied 
tanum 
Hydrocolpos 


verumon- 


renal  injury  by  urinary  back  pressure  (hydro- 
nephrotic  damage)  and  by  toxic  absorption 
consequent  to  declining  renal  function  or  from 
secondary  infection.  In  children  these  toxic  influ- 
ences are  sharply  reflected  by  fever  and,  in  the 
gastrointestinal  tract,  by  indigestion,  malaise, 
anorexia,  nausea,  vomiting,  constipation,  diar- 
rhea, anemia,  and  failure  to  gain  or  even  loss  of 
weight.  In  over  half  of  all  children  with  severe 
urinary  obstruction  and  renal  injury  the  gastro- 
intestinal symptoms  or  toxic  nervous  system  man- 
ifestations (nervousness,  headache,  convulsions) 
are  predominant  and  commonly  cause  the  uri- 
nary obstruction  to  be  overlooked.  Ihe  more 
important  symptoms  in  urinary  obstruction  in 


the  young  and,  by  the  same  token  those  which 
call  for  urologic  examination,  are  given  in  table  2. 

TABLE  2 

Indications  for  Urologic  Investigation 

1.  Pyuria 

a.  Acute,  persistent 

b.  Chronic 

2.  Disturbances  of  urination;  dysuria.  freriuency, 

urgency,  etc. 

3.  Hematuria  (except  acute  nephritis) 

4.  .Abdominal  pain 

5.  .Abdominal  tumor 

6.  .Anomaly  of  external  genitalia 

7.  Urogenital  injury 

8.  Hypertension 

9.  Renal  insufficiency 

10.  Enuresis 

11.  Spinal  cord  injury  and  disease 

12.  Retarded  growth 


Diagnosis 

Diagnosis  rests  upon  adequate  urologic  exami- 
nation, the  indications  for  which  are  given  in 
table  2.  The  investigative  steps  and  the  usual 
order  of  their  employment  are  shown  in  table  3. 

TABLE  3 

Routine  of  Urologic  Examination  in  Infants  and  Children 

1.  Careful  physical  examination — es])ecially  palpa- 

tion of  urinary  and  reproductive  tracts.  Rec- 
tal examination. 

2.  Examination  of  catheterized  urine  si^ecimens:  al- 

bumin, sugar,  pus,  blood,  l)acteria  (stain  and 
culture) 

3.  Two-hour  phenolsulfonphthalein  test  (intramus- 

cular) 

4.  Blood  chemistry  (nonprotein  or  urea  nitrogen, 

C(T) 

5.  Plain  film  of  urinary  tract  for  calculi  and  .sjunal  de- 

fects 

6.  Cystogram 

7.  Determination  of  residual  urine 

8.  Cystoscopy  (general  anesthesia  in  about  50%); 

a.  Observation  of  bladder  wall,  outlet,  and  pos- 

terior urethra 

b.  Ureteral  catheterization 

c.  Divided  renal  specimen  collection 

d.  Divided  renal  function  tests  (P.S.P.  or  indigo 

carmine) 

e.  Pyelography  when  indicated. 

Fortunately  it  is  not  always  necessary  to  perform 
all  of  these  studies  in  every  case,  but  the  exami- 


VOL.  XXI,  NO.  3 


Medical  Annals  of  the  District  of  Columbia 


125 


nation  should  be  pursued  to  a definitive  conclu- 
sion, it  being  possible  in  practically  each  instance 
to  make  a reasonably  accurate  anatomic  diagno- 
sis. 

Treatment 

Treatment  depends  upon  the  diagnostic  find- 
ings; the  fundamentals  of  therapy  are  the  eradi- 
cation of  the  obstruction  and  of  infection  and/or 
other  complicating  conditions.  The  blockage  hav- 
ing been  removed,  these  patients  should  not  be 
considered  cured  until  the  urine  has  been  steri- 
lized as  evidenced  by  at  least  2 negative  cultures 
of  aseptically  collected  specimens.  This  last  im- 
plies catheterization  in  females  of  all  ages  and 
also  in  males  when  proper  collection  cannot  be 
made  from  the  voiding  stream. 

In  many  cases  unilateral  renal  damage  is  so 
pronounced  that  only  nephrectomy  is  indicated; 
sometimes  both  the  kidney  and  ureter  must  be 
removed.  When  the  renal  damage  is  bilateral 
and  far  advanced  only  permanent  bilateral  ne- 
phrostomy offers  hope  of  preserving  life.  For- 
tunately the  happy  combination  of  young 
resilient  tissues  (especially  renal)  and  modern 
chemotherapy  and  'or  antibiotic  therapy  permit 
us  now  to  undertake,  with  every  prospect  of 
success,  major  urosurgical  procedures,  largely 
conservative,  which  only  10  years  ago  would 
have  been  deemed  hopeless  or  even  fatal.  With 
proper  attention  to  avoidance  of  trauma,  with 
control  of  infection,  and  with  the  employment  of 
modern  surgical  safeguards,  infants  and  children 
withstand  better  than  do  adults  complete  cysto- 
scopic  and  pyelographic  examination  as  well  as 
major  urosurgery.  Their  reactions,  febrile  or 
otherwise,  are  in  general  fewer  and  less  severe. 

Common  Forms  of  Obstruction 

In  the  following  paragraphs  are  briefly  dis- 
cussed some  of  the  more  common  and  imjiortant 
congenital  urinary  obstructions  in  the  young,  the 
clinical  and  therapeutic  management  of  which 
comprises  the  largest  portion  of  urologic  practice 
in  young  patients.  Many  of  the  more  severe  con- 


genital obstructions  are  fatal  in  infancy.  Because 
of  the  high  early  mortality  they  engender,  the 
graver  congenital  obstructions  are  rarely  ob- 
served in  adults  because  most  of  these  patients 
die  young. 

Congenital  stenosis  of  the  prepuce  is  an  ex- 
tremely rare  obstruction  which,  when  not 
promptly  recognized  and  corrected,  is  fatal  in 
early  neonatal  life.  I know  of  5 such  cases  in  the 
New  York  Metropolitan  Area,  with  death  oc- 
curring in  all  within  the  first  2 weeks  of  life. 
Circumcision  is  the  treatment. 

Stenosis  of  the  external  urethral  meatus  is  a 
common  congenital  obstruction  which  occurs 
with  ecjual  potential  severity  in  both  sexes,  al- 
though it  is  more  likely  to  be  recognized  in  the 
male  and  notably  when  complicating  ulcerative 
meatitis  and  perimeatitis  exists.  Urinary  diffi- 
culty and  frequency  with  great  straining  to  void 
and  the  passage  of  a fine  hairlike  sttLam  of  urine 
are  the  usual  symptoms.  Blood  on  the  clothing 
from  bleeding  ulcerative  meatitis  is  probably  the 
most  frequent  and  alarming  manifestation  which 
brings  these  male  children  for  relief.  In  the  fe- 
male, urinary  frequency  and  chronic  pyuria  are 
the  usual  symptoms,  but  in  many  the  clinical 
picture  has  caused  the  diagnosis  of  enuresis  to  be 
made.  The  diagnosis  of  meatal  stenosis  is  readily 
made  by  inspection;  urography  not  infrecjuently 
discloses  massive  dilatation  of  the  entire  proximal 
urinary  tract.  Wide  meatotomy  is  the  treatment. 
It  is  important  that  this  procedure  be  followed 
at  appropriate  intervals  with  meatal  dilation  by 
sounds,  usually  a week,  then  2 and  3 weeks  after 
meatotomy.  Parenthetically,  meatotomy  and  the 
maintenance  of  a normal  meatal  caliber  alone 
cures  ulcerative  meatitis. 

Congenital  stricture  elsewhere  in  the  urethra 
is  not  infre(|uent,  the  penoscrotal  junction  being 
the  usual  site  of  predilection,  although  I have 
encountered  the  condition  in  all  portions  of  the 
canal.  'I'he  symptoms  are  those  of  lower  tract 
obstruction;  secondary  urinary  infection  and 
pyuria  are  freciuent  complications,  as  are  urethral 
diverticula  and  calculi  jiroximal  to  the  obstruc- 
tion. The  diagnosis  may  be  susiiected  from  the 


126 


Congenital  Obstruction  of  Urinary  Tract — Campbell 


MARCH,  1952 


history  or  by  the  grasping  of  an  instrument  of 
normal  size  by  the  stricture,  and  is  confirmed  by 
urethroscopy.  Most  urethral  strictures  in  the 
young  respond  readily  to  periodic  progressive 
dilation  with  sounds;  rarely  is  internal  or  ex- 
ternal urethrotomy  necessary  and  only  when 
dilation  is  technically  impossible  or,  consistently 
employed,  has  failed  to  cure. 

Urethral  diverticulum  which  has  formed  as  a 
blowout  process  behind  a congenital  stricture 
may  disappear  following  adequate  dilation  of  the 
canal  but,  if  not,  demands  excision.  Calculi  form- 
ing in  these  pockets  or  developing  proximal  to 
urethral  stricture  require  removal,  transure- 
thrally  or  by  urethrostomy. 

Congenital  contracture  of  the  vesical  outlet, 
congenital  valves  of  the  prostatic  urethra,  con- 
genital hypertrophy  of  the  verumontanum,  and 
sphincterospastic  neuromuscular  vesical  disease 
consequent  fo  congenital  central  nervous  system 
spinal  malformation  are  4 obstructive  entities 
of  vital  import.  All  of  these  conditions  produce 
the  same  destructive  back-pressure  changes  in 
the  upper  urinary  tract,  cause  essentially  the 
same  clinical  manifestations,  and  require  the 
same  fundamental  treatment — eradication  of  the 
blockage  and  of  infection  and  other  complicating 
conditions  such  as  stone.  As  the  vesical  residual 
urine  increases  and  the  functional  bladder  capac- 
ity is  corresponsingly  diminished,  urinary  fre- 
quency becomes  pronounced  (even  every  10  or 
15  minutes),  and,  with  chronic  complete  reten- 
tion, overflow  with  paradoxical  or  pseudoincon- 
tinence appears.  Pyuria  denotes  secondary  uri- 
nary infection  as  may  hematuria,  but  the  last 
commonly  occurs  in  all  varieties  of  obstruction 
and  results  from  the  intense  congestion  of  the 
urinary  organs  above  the  point  of  blockage. 

In  most  of  these  cases  removal  of  the  obstruct- 
ing lesion  by  transurethral  resection  solves  the 
problem,  this  treatment  being  employed  only 
at  a time  when  the  condition  of  the  patient 
warrants.  In  patients  with  advanced  renal  dam- 
age by  urinary  back  pressure  and  infection,  pre- 
liminary cystostomy  drainage  is  indicated  ex- 


actly as  we  are  accustomed  to  employ  it  in  the 
preliminary  treatment  of  advanced  prostatic  ob- 
structive disease  in  adults.  The  prognosis  de- 
pends on  the  extent  of  the  renal  damage  by 
urinary  back  pressure  and  infection,  the  prompt- 
ness and  completeness  with  which  the  obstruc- 
tion is  removed,  and  the  response  of  infection 
to  treatment. 

Congenital  contracture  of  the  vesical  outlet 
occurs  as  a concentric  narrowing  in  both  sexes 
and  is  histologically  recognized  either  as  a sub- 
mucous fibrosis  or  as  a massive  muscular  over- 
growth lending  a remarkable  rigidity  to  the  tight 
bladder  orifice.  The  diagnosis  is  made  by  cysto- 
urethroscopy,  the  employment  of  a forward  vi- 
sion instrument  being  essential  for  the  identifi- 
cation of  this  lesion  as  well  as  for  all  other  ob- 
structions in  the  urethra  or  at  the  bladder  outlet. 
Not  only  will  the  smoothly  rounded  collar-like 
contracted  vesical  outlet  be  seen  but  also  the 
secondary  trigonal  hypertrophy,  the  trabecula- 
tion  and  muscular  hypertrophy  of  the  bladder 
wall  proper,  and  complicating  diverticula  or 
stone.  Determination  of  the  renal  function  by 
excretion  and  retention  tests  (blood  chemistry: 
nonprotein  nitrogen,  urea)  is  essential,  and  at 
least  a satisfactory  excretory  urographic  study 
should  be  made,  although  I prefer  the  retro- 
grade method.  Sometimes  by  vesicoureteral 
reflux  the  widely  dilated  upper  tract  is  demon- 
strated. Transurethral  resection  is  usually  satis- 
factory treatment,  being  performed  with  a 16 
F.  miniature  resectoscope,  the  introduction  of 
which  through  an  external  urethrostomy  is  re- 
quired in  infant  males  and  in  all  other  boys  when 
a diminished  urethral  caliber  demands.  In  the 
past  I have  often  satisfactorily  employed  the 
suprapubic  excision  of  a large  V-wedge  from  the 
inferior  segment  of  the  contracted  bladder  outlet 
and  still  consider  it  a thoroughly  satisfactory 
procedure  although  of  greater  surgical  magnitude 
than  transurethral  resection. 

Congenital  valves  of  the  prostatic  urethra  ap- 
pear as  large  mucosal  folds  which  are  usually 
attached  to  the  verumontanum  and  pass  an- 


VOL.  XXI,  NO.  3 


Medical  Annals  of  the  District  of  Columbia 


127 


teriorly,  laterally  or  posteriorly  to  the  urethral 
wall  and/or  vesical  outlet  respectively,  are  al- 
most always  bilateral,  and  are  not  to  be  confused 
with  the  normal  urethral  frenula.  Rarely  the 
valves  exist  as  an  iris  diaphragm-type  of  obstruc- 
tion. As  urine  strikes  these  valves  they  balloon 
in  cusp  formation,  urethroscopically  appearing 
much  as  cardiac  cusps.  The  symptoms  are  those 
common  to  deep  urethral  obstructions  as  pre- 
viously described,  usually  exist  from  birth,  and 
are  notably  those  of  the  urinary  difficulty.  The 
diagnosis  is  readily  made  by  cystourethroscopy; 
having  once  observed  a case,  a urologist  could 
scarcely  fail  to  recognize  the  condition  again. 
These  valves  should  be  removed  by  transurethral 
electroexcision. 

Congenital  hypertrophy  of  the  verumontanum 
is  a cellular  hypertrophic  lesion  in  which  the 
organ  frequently  becomes  3 to  5 times  normal 
size,  often  fills  the  deep  urethra,  in  some  cases 
even  extending  into  the  vesical  outlet  or  into 
the  bladder  cavity  itself,  and  in  all  events  pro- 
duces obstruction.  The  lesion  is  readily  recog- 
nized urethroscopically,  and  its  removal  by  trans- 
urethral resection  is  the  treatment. 

Sphincterospastic  neuromuscular  vesical  dis- 
ease is  a frequent  affliction  in  the  young,  in  whom 
it  is  usually  consequent  to  injury  or  malformation 
of  the  lower  spinal  cord  in  association  with  con- 
genital neurovertebral  fusion  anomalies.  The  ob- 
structive lesion  frequently  simulates  contracture 
of  the  vesical  outlet,  from  which  it  must  be 
differentiated,  a comprehensive  neurologic  ex- 
amination including  cystometry  being  an  es- 
sential part  of  the  study.  In  many  of  these  cases 
somatic  neural  changes  are  not  demonstrable.  It 
seems  likely  that  the  faulty  neurogenesis  here 
is  in  the  parasympathetic  nervous  system  with  a 
pronounced  reduction  in  the  number  of  ganglion 
cells  comparable  to  and  often  a part  of  this 
anomaly  in  congenital  megacolon  fllirsch- 
sprung’s  disease),  as  Swenson  and  his  co-workers 
have  demonstrated.  Although  the  treatment  of 
sphincterospastic  neuromuscular  vesical  disease 
is  often  extremely  difficult  and  commonly  un- 


satisfactory, excellent  results  have  been  achieved 
by  transurethral  resection  in  many  cases  and 
notably  in  those  simulating  contracture  of  the 
vesical  outlet.  When  this  fails,  permanent  supra- 
pubic cystostomy  drainage  will  perpetuate  life. 
In  general,  neurosurgery  has  little  to  offer. 

Congenital  obstructive  lesions  of  the  upper 
urinary  tract  are  essentially  those  involving  the 
ureter,  notably  stricture,  kinks,  and  vascular 
obstruction.  Congenital  stricture  of  a renal  calyx 
may  occur  with  the  development  of  localized 
hydronephrosis  and  sometimes  secondary  stone. 
In  all  obstructive  lesions  of  the  upper  urinary 
tract  abdominal  pain  or  pain  along  the  course  of 
the  ureter  tract  is  the  commonest  symptom  and 
by  visceral  reflex  is  frequently  manifested  by 
gastrointestinal  disturbances.  The  incidence  of 
complicating  urinary  infection  is  high,  and  many 
of  these  children  with  congenital  upper  tract 
obstruction  have  their  fundamental  lesion  identi- 
fied by  urologic  examination  demanded  by  per- 
sistent pyuria.  Hematuria  results  from  infection 
or  the  congestion  of  the  proximal  urinary  tract. 
By  visceral  reflex  or  by  systemic  toxemia  con- 
sequent to  advanced  renal  damage  and  dimin- 
ished renal  function,  the  same  gastrointestinal 
disturbances  may  appear  as  previously  described 
in  the  discussion  of  symptoms  of  congenital  uri- 
nary obstruction. 

The  diagnosis  of  congenital  upper  tract  block- 
age can  be  made  by  complete  urologic  investi- 
gation in  which  retrograde  urography  plays  an 
essential  role.  Excretory  urography  may  afford 
a preliminary  clue,  but  in  half  of  the  children  in 
whom  the  method  is  employed  the  results  are 
inconclusive  or  the  study  is  otherwise  unsatis- 
factory. For  this  reason  we  employ  retrograde 
urography  routinely  for  thorough  urologic  in- 
vestigation in  the  young  and  particularly  when 
surgical  therapy  is  likely  to  be  employed. 

Ureteral  stricture  occurs  congenitally  in  about 
1 per  cent  of  all  newborn  infants,  is  commonly 
bilateral,  and  is  found  more  often  at  the  uretero- 
vesical junction  than  at  the  ureteropelvic  junc- 
tion, being  least  freciuent  in  the  body  of  the 


128 


]VL\RCH,  1952 


Congenital  Obstruction  of  Urinary  Tract — Campbell 


ureter.  These  strictures  are  freciuently  multiple 
although  I have  not  encountered  more  than  3 
in  a ureter.  Histogenetically  many  of  these  stric- 
tures begin  as  mucosal  redundancies  with  angula- 
tion, looping,  and  fibrous  periureteral  fixation, 
while  in  others  they  are  simply  congenital  nonin- 
tlammatory  narrowings  comparable  to  similar 
congenital  narrowings  observed  in  the  intestinal, 
pulmonary,  biliary  and  vascular  tracts.  Dilata- 
tion occurs  in  the  ureter  above  the  point  of  ob- 
struction, and  the  nearer  the  blockage  is  to  the 
kidney,  the  earlier  and  more  severe  will  be  the 
resulting  hydronephrosis.  Frequently,  in  grave 
ureterovesical  junction  stricture,  lateral  dilata- 
tion increases  the  ureteral  caliber  to  the  size  of 
the  colon  and  by  longitudinal  dilatation  the 
ureteral  length  is  frequently  doubled,  this  re- 
sulting in  extreme  angulation,  tortuosity  and 
secondary  kinking.  This  kinking,  in  turn,  com- 
monly gives  rise  to  secondary  obstruction,  a 
point  of  great  therapeutic  importance  in  the 
surgical  treatment  of  these  cases,  since,  with 
adequate  relief  of  the  ureterovesical  junction 
stricture,  for  example,  free  renal  drainage  is  not 
always  afforded  because  of  the  ureteral  angula- 
tion or  kinking  above.  The  abdominal  pain 
caused  by  ureteral  stricture,  and  notably  when  it 
involves  the  lower  third  of  the  duct,  too  fre- 
quently leads  to  the  erroneous  diagnosis  of 
chronic  appendicitis  and  the  performance  o(  ap- 
pendectomy. 

Having  established  the  diagnosis  l)y  urologic 
e.xamination  including  ureteral  calibration  by 
the  exploratory  catheter  and  by  urography,  pe- 
riodic ]>rogressive  cystoscopic  dilation  of  the  stric- 
ture is  the  conservative  treatment  and  is  often 
thoroughly  effective  when  the  stricture  is  in  the 
lower  ureteral  segment.  Dilation  nearly  always 
fails  in  the  treatment  of  upjrer  ureteral  strictures. 

Surgical  treatment  must  be  employed  when 
conservative  dilation  fails  to  cure  or  when  this 
method  is  obviously  unwarranted  from  the  start. 
If  the  kidney  is  hopelessly  damaged,  nephrec- 
tomy or  ureteronephrectomy  wdth  removal  of  the 
duct  to  a point  below  the  obstruction  is  the 
indication.  In  bilateral  congenital  stricture  or 


when  the  kidney  must  or  can  be  saved,  tempo- 
rary or  permanent  nephrostomy  and  or  uretero- 
plastic  procedures  are  employed.  In  stricture  at 
the  ureteropelvic  junction  in  which  the  Foley- 
Schweizer  Y-plasty  operation  is  not  feasible  be- 
cause of  the  length  of  the  stricture-bearing  area, 
longitudinal  incision  through  the  constricted  seg- 
ment with  T-tube  intubation  after  the  method 
of  Davis  has  given  me  the  best  results.  This  last 
procedure  is  also  my  choice  when  the  stricture 
is  in  the  body  of  the  ureter  and  longitudinal 
dilatation  is  slight.  Whatever  method  is  em- 
ployed for  the  removal  of  the  ureteral  obstruc- 
tion, free  ureteral  drainage  must  be  maintained 
postoperatively  as  evidenced  by  cystoscopic  and 
orographic  check-up.  No  patient  is  cured  until 
both  the  blockage  and  infection  as  well  as  other 
complications  such  as  stone  have  been  eradi- 
cated. 

When  the  stricture  is  at  the  ureterovesical 
junction,  wide  incision  wdth  intubation  for  10 
days  postoperatively  is  frequently  effective,  as  is 
ureteroneocystostomy.  In  several  cases  I have  | 
employed  a pull-through  operation  in  which,  in 
addition  to  establishing  free  ureterovesical  junc- 
tion drainage,  several  inches  of  redundant  dilated 
ureter  can  readily  be  removed  at  the  same  time. 

Congenital  ureteral  kinks  are  extremely  rare. 
When  there  is  hrm  fixation  of  the  angulated 
segment  with  obstruction  or  symptoms,  surgical 
ureterolvsis  with  renal  suspension  is  the  treat- 
ment. 

Compression  and  obstruction  of  the  ureter  by 
anomalous  vessels,  both  arteries  and  veins,  have  [ 
been  observed  at  all  levels  of  the  duct.  We  are 
chietly  concerned  with  anomalous  lower  polar 
renal  vessels  which  are  found  in  at  least  25  per  , 
cent  of  all  individuals.  In  some  cases  the  obstruc- 
tion is  doubtless  primarily  caused  by  compres- 
sion of  the  ureter  by  the  anomalous  vessel 
traversing  it,  but  in  most  cases  the  obstruction  j 
is  secondary;  either  ureteral  dilatation  induced 
by  peripheral  obstruction  has  in  turn  comiiressed 
the  duct  against  the  vessel,  or  with  hydronephro- 
sis the  kidney  has  secondarily  sagged  over  the 
vessel  which  otherwise  would  be  blameless. 


VOL.  XXI,  NO.  3 


Medical  Annals  of  the  District  of  Columbia 


129 


The  symptoms  are  those  common  to  upper 
tract  obstruction,  “chronic  pyelitis”  being  the 
diagnosis  in  about  half  of  the  cases.  The  course 
of  the  obstructing  vessel  can  sometimes  be  uro- 
graphically  demonstrated  as  a negative  shadow 
traversing  the  ureter,  and  in  all  cases  the  site  of 
the  vascular  obstruction  can  be  thus  indicated. 
Urographic  differentiation  between  fibrous  band, 
ureteral  stricture  and  anomalous  blood  vessel  as 
the  cause  of  the  blockage  is  not  always  possible. 

Relief  of  the  obstruction  is  the  treatment  un- 
less advanced  renal  destruction  demands  nephrec- 
tomy, as  it  has  in  over  half  of  the  more  than 
50  infants  and  children  I have  seen  with  this 
condition.  When  the  kidney  can  be  saved,  the 
obstructing  vessels  are  divided  and  such  steps  as 
necessary  are  taken  to  insure  free  renal  drainage. 
In  general,  renal  veins  may  be  cut  with  impunity, 
but  no  artery  supplying  more  than  a fourth  of 
the  parenchyma  should  be  cut,  the  arterial  circu- 
lation here  being  a terminal  one.  Ureteroplastic 
procedures  are  employed  to  circumvent  an  ob- 
structing artery  which  must  not  be  cut.  The  high 
incidence  of  nephrectomy  demanded  in  these 
cases  may  be  considered  the  fruit  of  medical 
neglect. 


Summary 

The  commoner  congenital  obstructions  of  the 
urinary  tract  have  been  briefly  discussed.  Renal 
damage  with  hydronephrosis  and  complicating 
infection  are  the  prime  considerations.  The  symp- 
toms are  those  locally  engendered  by  the  obstruc- 
tion itself  and  toxic  manifestations  systemically 
reflected,  notably  in  the  gastrointestinal  tract 
and  nervous  system.  A correct  anatomic  diagno- 
sis can  be  made  in  practically  every  case  by 
adeejuate  urologic  examination.  The  prognosis 
depends  upon  the  severity  of  the  renal  damage 
and  complications,  and  the  promptness  and  com- 
pleteness of  therapy.  Treatment  is  carried  out 
according  to  surgical  indication.  In  many  pa- 
tients simple  conservative  measures  suffice  and 
are  lifesaving,  while  in  others  complicated  major 
urosurgery  is  demanded,  sometimes  with  mul- 
tiple-stage procedures.  Correct  early  diagnosis 
and  treatment  will  forestall  nephrectomy  and 
other  grave  urosurgery  in  a large  portion  of  these 
cases;  the  preventable  loss  of  a kidney  may  be 
considered  the  fruit  of  medical  neglect. 

140  East  54th  Street 
New  York,  N.  Y. 


THE  SURGICAL  TREATMENT  OF  PULMONIC 
STENOSIS* 


/ HE  surgical  treatment  of  pulmonic 
stenosis  is  confined  at  present  to  treat- 
ment of  congenital  lesions.  Pulmonic  stenosis 
can  be  divided  into  two  forms,  the  tetralogy  of 
Fallot  being  one,  the  so-called  “pure”  pulmonic 
stenosis  being  the  other.  The  “pure”  pulmonic 
stenoses  can  be  further  subdivided.  Approxi- 
mately 70  per  cent  of  “pure”  pulmonic  stenosis 
is  accompanied  by  an  interauricular  septal  defect. 
The  other  30  per  cent  have  no  associated  defects 
and  are  known  as  uncomplicated  pulmonic  steno- 
ses. In  a review  in  1949  Green  et  aP  were  able  to 
collect  only  68  cases  of  uncomplicated  pulmonic 
stenosis.  However,  there  is  reason  to  believe  that 
the  incidence  of  uncomplicated  stenosis  is  much 
higher  than  this.  Many  additional  cases  have 
been  seen  in  the  past  few  years  as  cardiac  surgery 
has  progressed  and  as  the  cardiac  catheter  has 
been  widely  used. 

The  anatomic  lesions  responsible  for  the  pul- 
monic stenosis  vary  considerably.  At  times  there 
is  atresia  of  the  pulmonary  artery,  although  this 
atresia  is  usually  accompanied  by  stenosis  of  the 
pulmonary  valve.  The  stenosis  may  be  confined 
to  the  pulmonary  valve,  the  3 valve  cusps  being 
fused  into  a cone-like  structure  with  an  opening 
of  variable  size  at  the  summit.  The  narrowed 
opening  causes  a jet  of  blood  to  enter  the  ])ul- 
monary  artery,  which  is  usually  dilated  just  dis- 
tal to  the  stenotic  valve.  The  cause  of  this  post- 
stenotic dilatation  is  unknown.  It  is  postulated 
that  the  jet  of  blood  is  responsible.  The  infundib- 
ular stenosis  may  be  below  the  pulmonic  valve 
in  the  infundibulum.  The  infundibular  stenosis 

* Address  delivered  before  the  Twenty-second  .\nnual 
Scientific  Assembly  of  the  Medical  Society  of  the  District  of 
Columbia,  October  1,  1951. 


EDWARD  J.  BEATTIE,  JR.,  M.D. 

Assisant  Professor  of  Surgery,  George  Washington  University 
School  of  Medicine 


may  be  short  or  fusiform.  A short  infundibular 
stenosis  may  be  near  or  some  distance  below  the 
pulmonic  valve.  The  anterior  wall  of  the  outflow 
tract  may  be  thin  or  relatively  thick. 

The  tetralogy  of  Fallot  is  the  commonest  form 
of  cyanotic  congenital  heart  disease.  Pulmonic 
stenosis,  interauricular  septal  defect,  overriding 
of  the  aorta,  and  hypertrophy  of  the  right  ven- 
tricle are  the  4 features  which  give  this  disease 
its  name.  Cyanosis  is  the  outstanding  clinical 
feature.  The  enlargement  of  the  right  ventricle 
and  the  decreased  pulmonary  artery  markings 
can  be  seen  in  the  X-ray  films  of  the  chest. 
Right  axis  deviation  is  present  in  the  electro- 
cardiogram. If  the  diagnosis  is  doubtful  use  of  the 
cardiac  catheter  demonstrates  the  increased  pres- 
sure in  the  right  ventricle.  If  the  catheter  can 
be  passed  into  the  pulmonary  artery,  the  hypo- 
tension will  be  found.  A ventricular  septal  defect 
may  be  demonstrated. 

The  prognosis  and  the  disability  in  a large 
degree  are  proportionate  to  the  oxygen  satura- 
tion of  the  arterial  blood.  Chronic  anoxia  with 
polycythemia  permits  only  a small  percentage 
of  patients  with  tetralogy  of  Fallot  to  survive  2 
decades  of  life  without  surgical  therapy. 

Uncomplicated  pulmonic  stenosis  has  the  fol- 
lowing diagnostic  features.-  There  is  usually  a 
systolic  murmur  heard  in  the  pulmonic  valve 
area.  The  pulmonary  artery  is  more  than  usually 
prominent.  There  are  normal  or  decreased  pul- 
monary vascular  markings  as  the  pulmonary 
arteries  are  followed  out  into  the  lungs.  The 
electrocardiogram  usually  shows  evidence  of 
right  ventricular  hyjjcrtrophy.  The  systemic  ar- 
terial oxygen  saturation  is  normal  unless  the 
patient  is  in  heart  failure.  The  diagnosis  can  be 


130 


VOL.  XXI,  NO.  3 


Medical  Annals  of  the  District  of  Columbia 


131 


proved  by  means  of  the  cardiac  catheter.  The 
catheter  will  reveal  high  pressures  in  the  right 
ventricle  but  low  pressures  in  the  pulmonary 
artery.  In  pulmonic  stenosis  with  interauricular 
septal  defect  there  will  be  a right  to  left  shunt 
through  the  auricles.  The  patient  will  suffer  from 
cyanosis  and  have  lowered  arterial  oxygen  satu- 
ration. 

Patients  with  “pure”  pulmonic  stenosis  of 
severe  degree  do  not  have  a much  different  prog- 
nosis than  the  patients  with  Fallot’s  tetralogy. 
Some  patients  with  uncomplicated  pulmonic 
stenosis  of  slight  degree  may  live  into  adult  life 
with  only  slight  disability.  The  decision  whether 
to  treat  patients  surgically  with  “pure”  pul- 
monic stenosis  depends  upon  the  degree  of  steno- 
sis and  the  disability  produced. 

The  surgical  treatment  of  pulmonic  stenosis  is 
limited  to  those  patients  with  inadequate  pul- 
monary artery  blood  flow.  This  condition  exists 
in  the  tetralogy  of  Fallot,  in  the  uncomplicated 
pulmonic  stenosis,  and  in  the  “pure”  pulmonic 
stenosis  with  an  interauricular  septal  defect.  The 
pulmonary  artery  blood  flow  is  not  inadequate 
in  patients  who  have  interauricular  septal  defects 
alone  or  Eisenmenger’s  complex.  Probably  no 
form  of  surgical  approach  has  had  as  rapid  and 
as  interesting  a history  as  that  of  the  develop- 
ment of  surgical  treatment  of  pulmonic  stenosis. 
The  first  surgical  attack  was  proposed  and  de- 
veloped by  Blalock  and  Taussig'*’  ® in  1944  for 
the  tetralogy  of  Fallot.  The  method  developed 
was  to  anastomose  the  end  of  the  subclavian 
artery  to  the  side  of  the  pulmonary  artery.  This 
permitted  an  additional  amount  of  unoxygen- 
ated systemic  blood  to  be  circulated  through  the 
lungs  for  oxygenation.  In  approximately  75  per 
cent  of  the  patients  with  the  tetralogy  of  Fallot 
a marked  improvement  of  the  cyanosis  occurred. 
In  1946  Potts®  introduced  his  operation  for  tetral- 
ogy of  Fallot  wherein  he  made  an  anastomosis 
between  the  aorta  and  the  pulmonary  artery. 
This  approach  had  distinct  advantages  in  infants. 
In  1948  Brock^’  * proposed  a direct  attack  of  the 
pulmonic  valve  itself.  In  a small  series  of  cases 
he  developed  instruments  and  technic  for  enter- 


ing the  heart  through  the  wall  of  the  right  ven- 
tricle and  relieving  the  stenosis.  In  cases  in  which 
the  stenosis  was  in  the  valve  a special  valvulo- 
tome was  devised  for  converting  the  stenosed 
valve  into  a bicuspid  valve.  For  those  cases  of 
pulmonic  stenosis  in  which  the  stenosis  was  in- 
fundibular in  nature  rather  than  or  in  addition 
to  the  pulmonic  stenosis  he  performed  an  in- 
fundibulotomy.  This  consisted  in  punching  out 
pieces  of  the  infundibulum  in  such  a fashion  that 
the  right  ventricular  outflow  tract  was  enlarged. 

The  best  form  of  treatment  in  the  various 
types  of  pulmonic  stenosis  is  still  open  to  con- 
siderable debate  and  is  changing  from  day  to 
day.®  Certain  statements  can  probably  be  made 
at  this  time.  First,  in  pure  pulmonic  stenosis 
with  or  without  a patent  foramen  ovale  the  best 
treatment  is  probably  a direct  approach  to  the 
stenosis  through  the  right  ventricle.  In  these 
patients  the  production  of  a left  to  right  shunt 
along  the  lines  of  a Blalock  or  Potts  operation 
may  only  make  the  condition  worse,  since  intro- 
ducing more  blood  into  the  right  auricle  has  the 
effect  of  raising  the  pressure  in  the  right  side  of 
the  heart  and  precipitating  right  heart  failure. 
In  the  tetralogy  of  Fallot  with  atresia  of  the  pul- 
monary artery  the  creation  of  a left  to  right 
shunt  is  the  only  form  of  treatment  available  at 
this  moment.  In  cases  of  the  tetralogy  of  Fallot 
in  which  the  stenosis  is  in  the  valve  the  direct 
approach  through  the  right  ventricle  may  prove 
to  be  the  preferable  form  of  treatment.  However, 
it  is  unfortunate  that  only  a minority  of  patients 
with  the  tetralogy  of  Fallot  have  the  stenosis  in 
the  valve.  The  majority  have  an  infundibular 
type  of  stenosis.  If  the  infundibular  stenosis  is 
short  the  direct  approach  is  feasible.  But  if  the 
infundibular  stenosis  is  long,  the  direct  attack 
becomes  much  more  diflicult  and  may  be  im- 
possible. The  best  type  of  surgery  for  this  type 
is  still  in  considerable  doubt. 

The  usual  method  for  carrying  out  a direct 
attack  on  the  pulmonic  valve  consists  in  making 
an  anterior  left  thoracic  incision.  The  ])cricar- 
dium  is  incised  longitudinally  anterior  to  the 
phrenic  nerve  and  a flap  of  pericardium  reflected 


\32 


Surgery  in  Pulmonic  Stenosis — Beattie 


MARCH,  1952 


medially.  Palpation  then  usually  reveals  the  di- 
lated pulmonary  artery.  If  there  is  pulmonic 
valve  stenosis  the  fused  cusps  can  be  felt  pro- 
truding into  the  lumen  of  the  pulmonary  artery. 
It  is  not  infrequent  that  as  the  chest  is  opened 
the  heart  action  rapidly  deteriorates.  Maneuvers 
to  relieve  the  stenosis  must  be  carried  out  forth- 
with, since  the  opening  of  the  stenosis  has  per- 
mitted satisfactory  resuscitation  of  some  pa- 
tients. Two  stay  sutures  are  placed  at  a point 
6 cm.  caudad  to  the  valve  ring.  A longitudinal 
incision  not  fjuite  through  the  endocardium  is 
made  into  the  myocardium.  A probe  is  then 
passed  through  the  incision  into  the  pulmonary 
artery  to  locate  the  position  of  the  stenosis.  If 
there  is  a valve  stenosis  a small -sized  valvulotome 
is  passed  in  a horizontal  fashion  into  the  pul- 
monary artery.  Larger  valvulotomes  are  used  to 
enlarge  the  opening  sufficiently.  The  valvulo- 
tomes are  followed  by  a sound  to  dilate  the  cut 
valve.  Hemostasis  is  secured  by  the  finger  until 
the  myocardium  is  sutured. 

If  the  stenosis  is  infundibular  the  problem  is 
more  difficult.  Diagnostic  angiocardiography  be- 
fore operation  and  palpation  of  the  e.xposed  heart 
at  operation  may  reveal  the  site  of  stenosis.  The 
heart  must  be  entered  above  or  below  the  steno- 
sis. If  the  stenosis  is  short,  the  opening  may  be 
enlarged  by  taking  bites  from  the  stenosis  with 


a specially  designed  punch.  If  the  stenosis  is 
long,  attempts  to  enlarge  the  narrowing  will 
probably  fail.  The  number  of  patients  with  this 
type  of  stenosis  is  not  yet  accurately  known.  It  is 
apparently  more  rare  than  the  short  infundibular 
stenosis.  It  is  to  be  hoped  that  a better  form  of 
therapy  for  the  long  stenosis  will  be  evolved. 

BIBLIOGRAPHY 

1.  Green,  D.  G.,  and  others;  Pure  congenital  pulmonary 

stenosis  and  idiopathic  congenital  dilatation  of  pul- 
monary artery.  .\m.  J.  Med.,  1949,  6,  24. 

2.  Dow,  J.  W.,  AND  others;  Study  of  congenital  heart  dis- 

ease; IV.  Uncomplicated  pulmonic  stenosis.  Circulation, 
1951,  1,  267. 

3.  Blalock,  .\.,  and  Taussig,  H.  B.;  Surgical  treatment  of 

malformations  of  heart  in  which  there  is  [)ulmonary 
stenosis  or  pulmonary  atresia.  J..\.M..\.,  1945,  128,  189. 

4.  Blalock,  and  Kieffer,  R.  F.;  Valvulotomy  for  relief 

of  congenital  valvulary  stenosis  with  intact  ventricular 
septum.  .\nn.  Surg.,  1950,  132,  496. 

5.  Blalock,  .\. ; Surgical  procedures  employed  and  anatomical 

variations  encountered  in  treatment  of  congenital  i)ul- 
monic  stenosis.  Surg.,  Gynec.  & Ohst.,  1948,  87,  385. 

6.  Potts.  VV.  J.,  Smith,  S.,  and  Gibson,  S.;  .\nastomosis  of 

aorta  to  jiulmonary  artery;  certain  types  in  congenital 
heart  rlisease.  J..V.M..\.,  1946,  132,  627. 

7.  Brock,  R.  C.;  Pulmonary  valvulotom\-  for  relief  of  con- 

genital jiulmonary  stenosis;  report  of  3 cases.  Brit.  M.  J., 
1948,  1,  1121. 

8.  Brock,  R.  C.;  Surgery  of  pulmonary  stenosis.  Ibid.,  1949, 

2,  399. 

9.  Glover,  R.  P.,  Bailey,  C,  P,,  .and  O’Xeill,  T.  J.  E.; 

Direct  (Brock)  relief  of  pulmonary  stenosis  in  tetralogv 
of  Fallot.  J.  Thoracic  Surg,,  to  he  published. 


THE  ENZYMATIC  DEBRIDEMENT  OF  WAR  WOUNDS 


COLONEL  A.  W.  SPITTLER,  M.C.,  U.S.A.,  Chief 
COLONEL  E.  W.  HAKALA,  M.C.,  U.S.A. 
MAJOR  E.  W.  MIDGLEY,  U.S.A. E.  (M.C.) 
C.\PTAIN  J.  W.  PAYNE,  U.S.A. E.  (M.C.) 

Slajf  Members,  Oiilwpedic  Section,  Waller  Reed  Army  Hospital, 
Washington,  D.  C. 


HE  purpose  of  this  paper  is  to  relate 
some  of  our  experience  at  Walter  Reed 
Army  Hospital  on  the  use  of  enzymes  in  the 
debridement  of  our  Korean  casualties. 

It  has  been  known  for  some  time  that  con- 
centrates of  streptococcal  filtrate  are  lytic  to 
fibrin  and  necrotic  tissue.  Tillett  and  GarneU-  ^ 
published  reports  in  1933  and  1934  showing  the 
fibrinolytic  activity  of  hemolytic  streptococci  and 
the  isolation  of  the  fibrinolytic  principle.  It  was 
later  shown  by  Tillett,  Sherry  and  Christensen^ 
that  30  to  70  per  cent  of  the  solids  of  inflam- 
matory pleural  exudates  was  a desoxyribose  nu- 
cleoprotein  and  the  viscidity  of  an  inflammatory 
coagulum  was  directly  proportional  to  the 
amount  of  nuclear  protein  present.  This  ;was 
found  to  originate  in  leukocytes  of  the  exudate. 
Tillett  et  aP  described  a desoxyribose  nuclease 
derived  from  streptococcal  filtrates  which  de- 
polymerizes  the  nucleoprotein.  I he  fibrinolytic 
principle  and  the  desoxyribose  nuclease  derived 
from  the  streptococcal  filtrate  were  called  strep- 
tokinase fSK)  and  streptodornase  (SD),  respec- 
tively. 

Tillett  and  Sherry^  and  others®-'®  have  re- 
ported excellent  results  with  the  use  of  the  SK 
and  SD  mixture  in  empyema,  chronic  osteo- 
myelitis and  pyogenic  arthritis.  Toxic  reactions 
were  minimal  and  consisted  of  transient  pyo- 
genic reactions  with  occasional  nausea,  vomiting 
and  leukocytosis,  particularly  when  used  in 
pleural  cavities. 

About  the  time  that  these  reports  were  being 


made,  Roettig"  reported  the  use  of  crystalline 
trypsin  in  the  treatment  of  empyema  with  results 
that  appeared  to  simulate  those  obtained  with 
SK-SD.  This  crystalline  form  of  trypsin  was 
obtained  from  the  beef  pancreas  and  prepared 
in  a 50  per  cent  magnesium  sulfate  form.  It  is 
stable  at  room  temperatures  in  dry  form  but 
loses  its  activity  in  solution  at  body  or  room 
temperature. 

Material  and  Methods 

Thirty-three  Korean  casualties  were  treated 
with  SK-SD. t The  material  furnished  was  ob- 
tained from  a filtrate  of  growing  cultures  of 
Lancefield  Group  C beta  hemolytic  streptococci. 
As  the  mixture  after  going  into  solution  is  un- 
stable at  room  temperature,  refrigeration  was 
used.  An  attempt  was  made  to  keep  the  pH  of 
the  wound  near  the  optimum  range  of  6.8  to  8.2 
as  shown  by  Kunitz'^  by  the  addition  of  acid 
sodium  phosphate.  Two  methods  of  application 
were  used.  In  the  one  group  an  ampule  of  SK-SD 
(10(),()()()  units  of  SK  with  40,000  of  SD)  was 
dissolved  in  2 to  10  c.c.  of  isotonic  sodium 
chloride  and  injected  into  the  oj)en  wound  be- 
neath a rubber  dam  glued  over  the  wound  edges. 
Sinuses  were  injected  directly  through  a {)oly- 
ethylene  tube.  The  position  of  the  patient  was 
maintained  to  allow  contact  with  the  solution 
and  substrate.  Another  group  was  treated  at 
the  suggestion  of  Sherry  with  a blend  in  a bland 
water  soluble  jelly  and  the  pH  adjusted  to  7 
by  the  addition  of  acid  sodium  phosphate.  I'his 


* .Vldress  delivered  before  the  Twenty-second  .\nnual  t The  Streptokinase-Streptodornase  (Varidase)  mixture 
Scientific  Assembly  of  the  .Medical  Society  of  the  District  of  was  suiiplietl  throunh  the  courtesy  of  l.ederle  l.aboratories, 
(.'olumbia,  October  1,  Ib.Sl.  N'ew  Nork,  X. 


133 


134 


MARCH,  1952 


Enzymatic  Debridement  of  War  Wounds — Spittler  et  al 


mixture  was  first  made  to  contain  10,000  units 
of  SK  and  3,600  of  SI)  per  gram.  This  was  later 
increased  5 times.  This  mixture  maintained  more 
continuous  contact  with  the  necrotic  tissue  than 
any  solution.  Unused  portions  of  the  mixture 
could  be  stored  under  ordinary  refrigeration  but 
lost  their  streptokinase  content  rapidly  while 
retaining  the  streptodornase  strength. 

Of  the  33  casualties  treated  during  this  series, 
20  were  of  open  wounds  with  exposed  bone,  7 of 
open  amputation  stumps,  and  6 of  gangrenous 
digits  following  frostbite. 

The  wounds  with  compound  fractures  were 
treated  through  windows  in  casts  by  either  the 
rubber  dam  or  jelly  method.  The  open  amputa- 
tion stumps  were  treated  by  applying  the  jelly 
mixture  to  the  stump  end  within  the  stockinette 
used  to  maintain  continuous  skin  traction.  The 
gangrenous  digits  were  treated  either  by  plastic 
bags  containing  the  solution  or  the  jelly  prepara- 
tion. The  treatment  was  carried  out  only  once  a 
day. 

Prior  to  treatment  the  bacterial  flora  was 
determined  and  sensitivity  tests  run  for  anti- 
biotics. The  appropriate  antibiotic  was  given 
throughout  the  treatment.  Sinus  depths  were 
determined  by  lipiodol  or  diodrast  injections  and 
X-ray  films.  Photographs  were  taken  before  and 
during  the  treatment.  The  SK-SI)  debridement 
was  continued  until  either  the  wound  closed  or  a 
secondary  operation  was  indicated  and  carried 
out. 

The  cases  selected  for  treatment  were  in  gen- 
eral those  not  amenable  to  any  good  immediate 
surgical  procedure  on  admission  or  would  not 
appear  to  respond  to  the  usual  nonoperative 
treatment  of  traction  in  the  case  of  amputation 
stumps.  All  patients  were  over  3 weeks  from  the 
time  of  injury  and  had  had  some  initial  debride- 
ment and  antibiotic  therapy  during  their  evacua- 
tion. 

All  showed  an  initial  response  with  an  increase 
in  drainage  in  the  first  48  hours.  The  exudate,  at 
first  viscid,  became  thin  and  watery.  The  mal- 
odor  of  the  drainage  gradually  disappeared  in 


the  first  few  days,  gratifying  to  the  patient. 
Although  cultures  showed  no  great  changes  in 
the  bacterial  flora  there  was  a quantitative  re- 
duction. 

Of  the  20  compound  fractures  or  open  wounds 
exposing  bone  4 were  about  the  ankle  or  foot 
with  a resultant  sinus  formation.  These  closed 
spontaneously.  Ten  granulated  over  the  exposed 
bone  rapidly  with  final  closure  with  split  thick- 
ness skin  graft  and  no  additional  bone  loss.  Six 
patients  needed  further  sequestrectomies  and 
other  surgical  procedures,  2 of  which  could  not 
be  considered  to  have  benefited  by  the  treatment. 
Of  the  7 amputation  stumps  there  was  an  ap- 
parent reduction  in  healing  time  of  4 to  6 weeks 
in  3.  The  usefulness  of  the  mixture  was  doubtful 
in  the  remaining  4 because  they  required  surgical 
release  of  the  skin  margins  to  effect  the  normal 
closure  needed  for  revision. 

In  the  weeping  wounds  of  the  digits  at  the 
demarcation  zone  between  normal  skin  and  the 
dry  eschar  the  use  of  the  SK-SD  mixture  seemed 
to  hasten  the  cleaning  up  of  this  process.  Since 
these  men  had  had  a comparatively  long  period 
allowed  for  definite  demarcation  the  aid  here 
was  chiefly  one  of  comfort  with  some  stimulation 
of  granulations  at  the  remaining  digital  stump. 

No  systemic  manifestations  were  encountered 
which  required  stopping  the  drug  nor  was  any 
unfavorable  viable  tissue  reaction  encountered 
except  in  2 cases  of  gangrenous  digits  treated 
with  an  impervious  dressing  encasing  the  entire 
foot. 

Although  the  products  are  known  to  be  anti- 
genic,^^ no  manifestations  of  allergy  were  found 
in  our  series. 

Twelve  additional  cases  were  treated  with 
crystalline  trypsin.*  Six  of  them  were  open  am- 
putation stumps,  2 were  open  wounds  with  ex- 
posed bone,  2 were  sinuses  to  bone,  and  2 were 
open  wounds  considered  failures  with  the  SK- 
SU  treatment. 

They  were  all  treated  with  250  mg.  doses  of  the 

* Crystalline  trypsin  (Tryptar)  was  sui)pliecl  through  the 
courtesy  of  .\rmour  Laboratories,  Chicago,  111. 


VOL.  XXI,  NO.  3 


Medical  Annals  of  the  District  of  Columbia 


135 


enzyme  in  a buffered  magnesium  sulfate  solution 
or  applied  directly  in  the  dried  crystalline  form. 
Sinuses  were  injected  through  a tube  or  filled 
with  soluble  capsules.  The  dosage  was  given 
every  3 hours  during  the  day. 


Fig.  1.  .\m|5utation  stump  before  treatment  with  crystalline 
trypsin. 

The  most  spectacular  results  were  in  the  am- 
putation stumps,  2 of  which  closed  in  4 weeks. 
The  remaining  4 had  several  weeks’  reduction 
in  traction  time  as  compared  to  similar  stumps 
but  required  further  surgical  assistance. 

Of  the  2 infected  compound  fractures  with 
exposed  bone,  granulation  continued  in  1 until 
closure  could  be  accomplished  in  6 weeks.  The 
other  required  surgical  removal  of  some  bone 
sequestra  with  later  skin  graft.  The  assistance 
of  the  treatment  was  doubtful  in  this  case. 

Of  the  2 sinuses,  1 closed  spontaneously  and 
remained  closed,  the  other  required  surgical  ex- 
ploration and  removal  of  a hidden  sequestrum 
which  may  have  become  better  delineated  by 
treatment. 

In  the  2 cases  considered  failures  with  SK-SD 
there  was  no  important  response  to  trypsin  treat- 
ment, and  the  patients  probably  should  have 
been  subjected  to  more  definitive  surgery  earlier. 
They  had  multiple  exposures  of  bone  and  numer- 
ous sequestra.  - 

All  the  amputees  complained  of  burning  on 
their  stump  ends  when  treated  with  the  powder. 


This  may  have  been  due  to  the  magnesium  sul- 
fate. The  use  of  benadryl  and/or  buffering  a 
solution  controlled  it.  There  was  a more  rapid 
hyperemia  and  increase  in  fluid  than  in  the 
patients  treated  with  SK-SD.  This  continued 
throughout  the  treatment  and  seemed  to  produce 
a wound  more  cjuickly  adaptable  to  skin-grafting 
than  was  formerly  produced. 

There  was  no  general  ill  effect  from  the  dosage 
used  except  a slight  increase  in  temperature  in 
those  cases  showing  a local  effect  in  a large 
wound. 

Figures  1 and  2 show  an  amputation  stump 
before  and  after  (4  weeks)  treatment. 


Fig.  2.  Same  stump  as  in  figure  1 after  4 weeks  of  treatment. 


Conclusions 

Enzymatic  debridement  is  a useful  adjunct  in 
the  treatment  of  infected  open  wounds.  Tt  will 
not  replace  adequate  surgical  debridement  and 
specific  antibiotic  therapy  but  will  shorten  the 
interval  in  preparing  a necrotic  wound  for  sur- 
gery. Some  sinuses  difficult  to  treat  surgically 
may  be  closed  without  surgery.  There  appears 

(Continued  on  pa^c.  ISO) 


RECENT  ADVANCES  IN  IMMUNIZATION 
PRACTICES*^ 


WILLIAM  ALLEN  HOWARD,  M.D. 

Associate  in  Pediatrics,  George  Washington  University  School 
of  Medicine 


C MM  UN  IZATION  against  certain  of 

the  communicable  diseases  is  an  integral  part 
of  preventive  medicine  and  one  of  the  most 
potent  factors  in  the  improvement  of  child 
health.  New  vaccines  are  being  developed,  old 
ones  are  being  improved,  and  the  scope  of  disease 
control  by  active  and  passive  immunization  is 
being  widened.  As  a result  the  practitioner  who 
cares  for  children  has  been  recjuired  to  make 
frecjuent  revisions  in  his  immunization  routine 
in  order  to  take  full  advantage  of  newer  develop- 
ments and  newer  materials  which  are  available. 

Although  every  effort  is  being  made  to  im- 
j)rove  the  vaccines,  many  studies  have  been 
directed  toward  establishing  the  optimum  time 
for  the  administration  of  these  antigens.  Em- 
phasis has  been  placed  on  determining  just  how 
early  in  life  immunizations  can  be  given  with 
satisfactory  results,  especially  in  the  case  of 
pertussis.  It  is  now  evident  that  the  very  young 
infant,  under  the  age  of  6 months,  can  and  does 
develop  an  active  immunity  when  given  the 
proper  antigen.  Age  may  be  a possible  factor  in 
limiting  the  degree  of  immunologic  response  of 
the  infant,  but  more  important  is  the  fact  that 
the  passively  transferred  immunity  received  by 
the  infant  from  its  mother  definitely  inhibits  the 
development  of  active  immunity  so  long  as  pas- 
sively transferred  immune  bodies  are  present. 
Passive  immunity  not  only  interferes  with  the 
development  and  maintenance  of  high  antibody 
titers,  but  also  tends  to  inhibit  the  development 

* From  the  Dei)artment  of  Pediatrics,  George  Washington 
University  School  of  Medicine,  and  the  Allergy  Clinic,  Chil- 
dren’s Hospital,  Washington,  D.  C. 

t .Uddress  delivered  l)efore  the  Twenty-second  .\nnual 
Scientific  Assembly  of  the  Medical  Society  of  the  District  of 
Columbia,  October  3,  19,31. 


of  the  capacity  to  respond  to  secondary  stimula- 
tion. This  effect  is  most  noticeable  in  infants  im- 
munized before  the  age  of  months  but  is  absent 
by  6 months.  Therefore,  additional  efforts  are 
being  made  to  determine  the  optimum  time  for 
the  administration  of  recall  or  booster  doses  in 
order  to  maintain  high  levels  of  immunity. 

Too  often  stress  is  placed  on  providing  the 
highest  possible  level  of  immunity  to  each  disease 
with  a good  deal  less  attention  paid  to  the  num- 
ber of  injections  recjuired  to  produce  this  high 
level.  As  a result,  in  some  of  the  reports  dis- 
cussing immunization  routines  one  finds  that 
infants  are  being  given  injections  for  indefinite 
periods,  beginning  in  the  first  few'  weeks  of  life 
and  continuing  for  every  visit  during  the  first 
year.  Many  of  the  reported  series  were  collected 
in  welfare  stations  and  institutionalized  groups 
where  reception  of  such  offerings  is  somewhat 
different  than  obtains  in  private  practice.  With 
full  regard  for  the  public  health  value  of  immuni- 
zations, but  with  due  consideration  for  the  in- 
fant, we  must  compromise  on  a routine  which 
will  assure  adequate  prophylaxis  without  un- 
necessary strain  on  the  infant.  Briefly,  our  goal 
would  be  to  provide  maximum  early  protection 
with  a minimum  number  of  injections. 

Pertussis 

Immunization  against  whooping  cough  is  a 
relative  newcomer  to  the  field  of  routine  im- 
munizations and  has  the  doubtful  distinction  of 
being  the  least  effective.  It  has  also  caused  most 
of  the  unfavorable  reactions.  Modification  of 
the  old  saline  suspension  of  killed  bacteria  by 
precipitation  wdth  alum  and  by  combining  it 


136 


VOL.  XXI,  NO.  3 


Medical  Annals  of  the  District  of  Columbia 


137 


with  other  antigens  has  improved  its  efficacy 
and  lessened  its  unpleasant  side-effects,  but  per- 
tussis immunization  remains  a major  problem. 

Because  the  bulk  of  pertussis  mortality  occurs 
prior  to  the  age  of  7 months,  and  because  per- 
tussis antigen  until  recently  has  rarely  been 
given  prior  to  the  age  of  6 months,  most  interest 
has  been  displayed  in  earlier  use  of  the  vaccine, 
even  as  early  as  the  neonatal  period.  The  success 
of  pertussis  immunization  is  measured  clinically 
by  apparent  protection  from  disease  and  lack  of 
unpleasant  side-reactions,  and  in  the  laboratory 
by  the  agglutination  response.  Agglutinin  titers 
of  1 :320  after  active  immunization  appear  to  be 
associated  with  clinical  immunity,  although  there 
is  no  evidence  that  the  agglutination  reaction 
plays  any  part  in  the  immunity  mechanism,  or 
even  that  the  reaction  occurs  at  all  in  vivo.  The 
in  vitro  result  must  always  be  checked  against 
the  actual  performance  of  the  vaccine  in  vivo.  A 
skin  test  was  also  developed  as  an  aid  in  deter- 
mining immunity  to  pertussis,  a special  pertussis 
agglutinogen  being  used.  Results  with  this  ma- 
terial have  been  equivocal,  and  it  has  not  been 
released  as  a commercial  skin  test  antigen. 

Experiments  indicate  that  3 or  even  2 doses 
of  alum-precipitated  or  aluminum  hydroxide- 
absorbed  pertussis  vaccine,  when  administered 
at  monthly  intervals  beginning  as  early  as  the 
first  week  of  life,  will  produce  agglutination  re- 
sponses in  more  than  60  per  cent  of  infants. 

1 However,  in  only  half  of  these  are  titers  up  to  the 
1:320  level,  supposedly  consonant  with  clinical 
; immunity.  When  the  injections  are  begun  at  3 
I months  of  age,  up  to  60  per  cent  show  so-called 
I protective  titers. 

I The  efficacy  of  the  vaccine  should  not  be 
judged  on  these  figures  alone.  On  the  basis  of 
information  obtained  from  immunized  groujis 
subject  to  household  exposure  it  appears  that 
1 titers  of  1 :320  were  associated  with  complete 
I protection,  while  in  children  with  titers  of  1 : 160 
or  less  the  attack  rate  was  33  per  cent,  d'hus  in 
I the  group  inoculated  under  the  age  of  3 months 
I one  may  estimate  that  regardless  of  titer  only 
25  per  cent  of  the  exposed  infants  will  develop 


pertussis,  whereas  among  non-immunized  groups 
with  negative  titers  the  attack  rate  after  house- 
hold exposure  is  from  75  to  90  per  cent.  This 
indicates  significant  protection  in  spite  of  the 
degree  of  agglutination  response.  Therefore,  re- 
gardless of  how  early  the  vaccine  is  administered, 
some  beneficial  effects  are  to  be  expected  at  a 
time  when  they  are  most  needed.  The  age  at 
which  the  vaccine  is  first  given  must  be  decided 
on  the  basis  of  local  necessity  or  desirability. 

The  dosage  rec|uired  to  give  adequate  im- 
munity under  ordinary  conditions  depends  upon 
the  type  of  vaccine  used.  In  the  old  saline  type 
at  least  100  billion  organisms  were  reejuired. 
With  the  use  of  alum  preparations,  especially 
those  in  combination  with  other  antigens,  im- 
munity is  more  easily  attained.  There  is  no  com- 
plete agreement  as  to  optimum  dosage,  but  a 
total  of  40  to  60  billion  organisms  is  usually 
considered  adequate.  Since  there  appears  to  be 
a direct  relationship  between  the  size  of  the  dose 
and  the  number  and  extent  of  reactions  which 
occur,  one  must  compare  the  toxicity  which  may 
result  from  higher  doses  with  the  failures  which 
may  result  from  smaller  quantities.  Booster  doses 
of  pertussis  vaccine  are  required  at  the  time  of 
known  exposure  and  at  2-  to  3-year  intervals. 
A saline  suspension  of  10  billion  pertussis  or- 
ganisms is  more  suitable  for  a recall  dose  at  the 
time  of  exposure. 

Reactions  to  pertussis  vaccine,  other  than 
local  reactions  to  be  discussed  later,  have  con- 
sisted primarily  of  fever  of  varying  severity  and 
duration.  Temperatures  of  104°  F.  or  more  are 
not  uncommon  with  the  saline  suspension.  Al- 
though rare,  true  encephalopathy  has  been  re- 
ported following  pertussis  immunization  and  has 
been  severe  enough  to  produce  permanent  neu- 
rologic sc(iuelae  or  death.  As  pointed  out  pre- 
viously, the  newer  vaccines  seem  to  have  lessened 
the  threat  of  such  comj)lications  considerably, 
d'here  is  definite  agreement  that  pertussis  vaccine 
in  an}'  form  should  be  given  with  caution  to  any 
child  with  a history  of  convulsions  and  should 
not  lie  administered  to  a child  with  active  infec- 
tion. In  doubtful  cases  it  is  ajijiropriate  to  reduce 


138 


Immunization  Pract ices — Howard 


MARCH,  1952 


the  dosage  and  increase  the  number  of  injections 
until  the  effect  of  the  vaccine  can  be  ascertained. 

Diphtherl\ 

There  is  fairly  general  agreement  that  alum- 
precipitated  or  aluminum  hydroxide-adsorbed 
toxoids  are  ideal  in  active  immunization  against 
diphtheria.  Some  dissenters  believe  that  no  type 
of  alum  toxoid  should  be  used  and  prefer  to  em- 
ploy the  less  effective  fluid  toxoid,  giving  extra 
doses.  Although  an  extraneous  or  foreign  mate- 
rial is  introduced,  its  principal  effect  seems  to  be 
to  delay  absorption  of  the  toxoid  and  prolong 
the  antigenic  stimulus,  creating  higher  levels  of 
immunity.  The  use  of  diphtheria  toxoid  in  com- 
bination with  other  antigens  (usually  tetanus 
toxoid  and/or  pertussis  vaccine)  appears  to  en- 
hance the  antigenic  potency  of  each. 

Diphtheria  toxoid  has  been  used  most  often 
beginning  at  or  after  the  age  of  6 months,  at  a 
time  when  the  immunity  mechanism  is  entirely 
adequate.  It  is  now  evident  that  a satisfactory 
immune  response  is  obtained  when  the  toxoid  is 
administered  in  the  usual  fashion  beginning  at 
the  age  of  3 or  4 months,  and  such  a routine  has 
now  become  common  practice.  Some  response 
may  be  obtained  when  diphtheria  prophylaxis 
is  completed  during  the  first  3 months  of  life, 
although  there  is  interference  from  passively 
transferred  immunity.  As  noted  above,  immune 
response  is  greater  when  diphtheria  to.xoid  is  com- 
bined with  another  antigen,  such  as  pertussis. 

A newer  type  of  alum 'toxoid,  designated  as 
purogenated,  is  now  in  general  use.  This  is  a 
toxoid  in  which  extraneous  nitrogenous  material 
is  precipitated  with  methanol.  It  is  claimed  that 
this  procedure  removes  over  99  per  cent  of  such 
unnecessary  nitrogen  and  thereby  allows  for  the 
use  of  much  less  alum  than  was  formerly  recjuired 
for  precipitation.  This,  in  turn,  tends  to  make  the 
product  less  likely  to  cause  local  reactions.  These 
reactions  will  be  discussed  in  detail  in  conjunc- 
tion with  the  discussion  of  combined  antigens. 

The  Schick  test,  for  years  used  as  the  standard 
for  determining  the  presence  or  absence  of  diph- 


theria immunity,  will  point  out  the  occasional 
child  who  has  not  developed  a protective  titer 
of  antitoxin.  Some  doubt  has  been  cast  upon  the 
ability  of  a negative  Shick  test  to  indicate  a truly 
protective  level  of  antibody,  but  with  the  dis- 
qualification of  the  pertussis  agglutinogen  skin 
test,  the  Schick  test  is  the  only  means  available 
to  the  clinician  which  gives  any  evidence  of  the 
ability  of  the  individual  to  respond  properly  to 
an  antigenic  stimulus.  Once  this  fact  has  been 
established,  the  Schick  test  may  be  eliminated 
in  favor  of  booster  or  recall  doses. 

Cellular  immunity  to  diphtheria,  once  estab- 
lished, may  remain  for  many  years,  but  it  is  in- 
sufficient to  furnish  protection  to  the  individual 
unless  it  is  stimulated  at  intervals  to  increase  the 
amount  of  circulating  antibody.  There  is  general 
agreement  that  the  first  recall  dose  should  be 
given  1 year  after  completion  of  the  basic  series. 
After  this,  repetition  every  2 to  4 years  is  recom- 
mended. 

Tetanus 

In  general,  the  statements  made  with  regard 
to  diphtheria  hold  true  for  immunization  against 
tetanus.  As  a matter  of  fact,  the  2 are  so  often 
used  in  combination  that  it  is  almost  impossible 
to  obtain  data  on  immunization  against  tetanus 
alone.  Although  protection  against  tetanus  has 
proven  its  value  many  times  over  in  both  military 
and  civilian  situations,  it  was  somewhat  slowly 
accepted  as  a standard  immunizing  agent  in  pedi- 
atrics. Now  that  it  is  so  often  and  so  easily  com- 
bined with  the  other  common  antigens  there 
seems  to  be  no  valid  excuse  for  its  omission.  Most 
important  to  remember  is  that  in  the  majority  of 
cases  of  tetanus  in  children  one  cannot  elicit  a 
history  of  recent  injury,  or  else  the  injury  was  so 
trivial  that  no  thought  was  given  to  the  necessity 
of  giving  either  antitoxin  or  a recall  dose  of  teta- 
nus toxoid.  For  this  reason,  if  for  no  other,  it  is 
desirable  to  obtain  and  maintain  a high  level  of 
tetanus  immunity.  To  this  end  booster  doses  are 
recommended  at  least  every  3 years.  Routine 
boosters  may  be  given  with  alum  toxoids,  but 
boosters  at  the  time  of  injury  should  be  with  the 


VOL.  XXI,  NO.  3 


■Medical  Annals  of  the  District  of  Columbia 


139 


more  rapidly  absorbed  fluid  to.xoid  which  gives 
a more  prompt  antibody  response. 

Once  basic  immunity  to  tetanus  has  been 
established  why  should  not  a tetanus  infection 
itself  be  sufficient  to  furnish  enough  toxin  to  act 
as  an  antigenic  stimulus  for  additional  protec- 
tion? Although  logical  on  theoretical  grounds 
the  belief  has  no  basis  in  fact.  This  is  amply 
demonstrated  by  the  evidence  that  the  patient 
just  recovered  from  tetanus  fails  to  respond  to 
the  recall  dose  of  tetanus  toxoid  as  does  the  person 
who  has  been  actively  immunized. 

At  this  point  mention  should  be  made  of  passive 
prophylaxis  against  tetanus  in  the  absence  of 
previous  active  immunization.  From  previous 
experience  it  is  apparent  that  the  former  dose  of 
1,500  units  of  tetanus  antitoxin  is  too  small  for 
adequate  protection.  It  is  suggested  that  the 
initial  dose  be  at  least  5,000  units  and  preferably 
10,000  units,  depending  upon  the  location,  nature 
and  severity  of  the  wound.  In  addition,  there  i.s 
justification  in  some  instances  for  repeating  the 
injection,  although  protective  levels  of  antitoxin 
may  circulate  for  several  days. 

In  some  cases  in  which  injury  necessitates 
prophylaxis  against  tetanus,  it  may  be  discovered 
that  active  immunization  has  been  given  so  long 
ago  that  it  is  doubtful  that  cellular  immunity 
has  been  maintained,  or  there  may  be  some  ciues- 
tion  as  to  the  adequacy  of  the  original  series. 
In  these  situations  or  where  the  nature  of  the 
wound  makes  it  especially  dangerous  fluid  toxoid 
and  full  doses  of  antitoxin  should  be  used.  If  this 
combination  is  employed,  it  is  probable  that  as 
long  as  significant  amounts  of  antitoxin  are  pres- 
ent in  the  circulation  the  effect  of  the  recall  dose 
will  be  depressed  or  delayed. 

Combined  Immunizations 

As  mentioned  earlier,  one  of  the  j)rime  prob- 
lems in  immunizing  infants  is  to  obtain  some 
combination  of  antigens  which  will  give  adecjuate 
immunity  and  at  the  same  time  reduce  the  num- 
ber of  injections  required.  long  stej)  in  the  right 
direction  was  the  development  of  a mixture  of 


diphtheria  and  tetanus  toxoids  and  pertussis  vac- 
cine. Here  in  one  mixture  are  the  3 important 
materials  for  immunizing  the  infant  and  young 
child.  The  combination  is  available  in  fluid  form 
as  well  as  in  the  alum-precipitated  and  alumi- 
num hydroxide-adsorbed  varieties  and  in  the 
newer  purogenated  forms.  Every  one  of  the  latter 
is  recommended  for  routine  use  in  infants  and 
children. 

The  combined  antigens  may  be  begun  as  early 
as  3 months  of  age  with  results  which  differ 
little  with  those  obtained  when  the  same  material 
is  administered  beginning  at  the  age  of  6 months. 
Reactions  also  differ  only  slightly  in  these  2 age 
groups.  In  those  cases  in  which  it  is  desirable  to 
secure  protection  against  pertussis  as  early  as 
possible,  this  may  be  done  with  2 doses  of  alum- 
precipitated  triple  toxoid,  given  at  intervals  of  4 
weeks  and  beginning  at  the  age  of  4 to  8 weeks. 
Although  this  may  fail  to  produce  adequate 
protection  against  diphtheria,  this  can  be  assured 
by  giving  the  third  dose  of  triple  toxoid  at  20 
to  24  weeks  of  age.  Such  a program  has  the  ad- 
vantage of  early  protection  against  pertussis  with 
eventual  adequate  protection  against  both  diph- 
theria and  tetanus.  Also,  the  triple  combination 
has  helped  to  solve  the  problem  of  booster  doses, 
since  a single  injection  of  the  combined  vaccine 
serves  as  an  adecjuate  booster  for  all  components 
of  the  antigen  when  given  to  persons  previously 
immunized  to  all  3 components. 

Local  reactions  to  combined  fluid  toxoids  have 
usually  been  slight  and  transient,  but  general 
reactions  to  fluid  antigens  are  occasionally  severe. 
There  may  be  considerable  fever,  malaise,  and 
even  convulsions  and  encephalopathies,  as  seen 
following  pertussis  vaccine.  With  the  develop- 
ment of  the  i)recipitated  antigens,  systemic  re- 
actions have  been  decreased,  apparently  due  to 
slower  absorption  in  the  system.  The  local  re- 
actions, although  fewer  than  with  fluid  toxoids, 
have  been  more  severe.  The  usual  local  reaction 
consists  of  the  development  of  a small  nodule  or 
alum  cyst  at  the  site  of  injection.  In  some  in- 
stances this  nodule  may  persist  for  weeks  before 


140 


1 m m unization  P r act i ccs — Howa rd 


MARCH,  1952 


disappearing;  at  other  times  the  cyst  may  rup- 
ture and  drain,  leaving  a small  scar.  Occasionally 
incision  and  drainage  of  the  fluctuant  area  may 
be  required.  These  alum  abscesses  were  fairly 
common  with  the  earlier  precipitated  prepara- 
tions, but  with  further  purification  and  concen- 
tration they  are  met  with  much  less  frequently. 

The  method  of  injection  is  an  important  factor 
in  the  development  of  these  abscesses.  A true 
subcutaneous  or  intramuscular  injection  will 
rarely  be  followed  by  a local  reaction  other  than 
transient  redness.  If  any  part  of  the  material  is 
introduced  intracutaneously,  alum  abscess  is 
more  likely  to  occur.  The  larger  doses  used  before 
the  concentrated  materials  were  available  also 
contributed  to  the  development  of  local  re- 
actions. Clearing  the  needle  with  a bit  of  air  to 
avoid  leaving  a track  of  toxoid  through  the  skin 
may  be  helpful.  I have  never  found  it  necessary 
to  change  needles  before  injecting  the  toxoid  in 
order  to  use  one  free  of  alum,  nor  do  I inject  the 
material  distally  as  is  occasionally  recommended. 
The  injections  are  most  easily  and  conveniently 
given  in  the  triceps  area,  but  the  buttocks  may 
be  used  provided  the  injection  is  given  deep 
enough.  The  skin  over  the  triceps  area  is  rela- 
tively insensitive  and  the  muscle  mass  smaller 
and  less  used,  making  this  a more  suitable  area 
for  injection  than  the  area  of  the  deltoid.  In 
several  thousand  injections  of  the  alum-precipi- 
tated purogenated  toxoids  administered  in  the 
past  3^  years  I have  not  encountered  a single 
abscess  and  only  an  occasional  cyst  which  has 
disappeared  spontaneously. 

Within  the  past  few  months  a new  and  most 
important  problem  has  risen  with  respect  to 
complications  of  immunizing  injection.  E.xperi- 
ences  with  poliomyelitis  in  England  and  Aus- 
tralia, coupled  with  similar  observations  in  the 
United  States  (notably  in  the  Minneapolis  epi- 
demic of  1946)  have  indicated  a possible  connec- 
tion between  the  site  of  injection  of  immunizing 
and  therapeutic  materials  and  the  location  of 
paralysis  in  certain  patients  with  poliomyelitis. 
In  substance,  the  published  evidence  indicates 
that: 


1.  Recent  injections,  given  within  4 weeks 
of  the  onset  of  poliomyelitis,  may  be  a factor  in 
conditioning  the  location  of  paralysis  if  paralysis 
is  to  result  from  the  attack. 

2.  Antigen  injection  may  be  a factor  in  tipping 
the  balance  toward  paralysis  in  a case  which 
might  otherwise  be  nonparalytic. 

3.  There  is  no  evidence  of  any  relationship  to 
any  particular  antigen  injected. 

4.  The  immunized  child  is  no  more  susceptible 
to  poliomyelitis  or  paralysis  from  poliomyelitis 
than  is  the  non-immunized  child  after  the  first 
month  following  inoculation. 

5.  The  danger  is  apparently  significant  only 
during  times  of  increased  prevalence  of  polio- 
myelitis. 

To  date  no  evidence  is  available  to  indicate 
how  the  antigen  injection  may  operate  to  aid  in 
the  development  of  paralysis.  It  has  been  as- 
sumed by  many  that  poliomyelitis  was  acquired 
separately  and  that  the  injection  simply  served 
to  increase  the  danger  of  paralysis  in  the  limb 
used  for  injection.  One  competent  observer,  on 
the  contrary,  has  suggested  that  in  most  of  the 
reported  cases  the  onset  of  paralysis  after  antigen 
injection  has  corresponded  within  certain  limits 
to  what  is  known  of  the  incubation  period  of 
poliomyelitis,  and  believes  that  possibly  the 
poliomyelitis  virus  is  introduced  locally  at  the 
time  of  inoculation  into  the  superficial  nerves. 
If  this  were  true  the  incubation  period  should  be 
shorter  when  the  injection  is  given  in  the  arm  as 
compared  to  administration  into  the  lower  ex- 
tremity. This  difference  was  evident  in  one  series 
analyzed,  where  the  average  incubation  period 
(time  between  injection  and  onset  of  paralysis) 
was  11.2  days  for  inoculations  given  in  the  arm 
and  17.7  days  for  inoculations  given  in  the  lower 
extremity. 

As  mentioned  previously,  many  injection  tech- 
nics are  employed  and  there  is  considerable  vari- 
ation in  the  manner  in  which  needles  and  syringes 
are  sterilized,  ranging  from  the  use  of  the  auto- 
clave to  the  often  hasty  boiling  of  the  syringe  in 
the  home.  Various  types  of  skin  antisepsis  are 


VOL.  XXI,  NO.  3 


Medical  Annah  of  the  District  of  Columbia 


141 


used,  needles  may  be  from  | to  1 inch  in  length, 
and  the  injection  may  be  given  subcutaneously, 
intramuscularly,  or  (inadvertently)  intracutane- 
ously.  Therefore,  it  becomes  well  nigh  impossible 
to  assess  the  role  of  injection  in  introducing  the 
virus.  It  would  seem  logical  to  assume  that  the 
less  trauma  inflicted  by  the  injection  the  less 
likely  would  damage  result  to  muscles  or  nerves 
which  might  predispose  to  later  localization  of 
the  virus,  if  such  is  a factor  in  production  of 
paralysis. 

A conservative  viewpoint  of  the  present  prob- 
lem may  be  summed  up  as  follows; 

1.  Syringes  and  needles  used  for  all  types  of 
inoculations  should  be  sterilized  by  autoclaving 
or,  if  this  is  impractical,  by  boiling  for  20  minutes. 

2.  Primary  immunization  against  diphtheria, 
tetanus,  and  pertussis  may  be  given  at  any  age 
when  poliomyelitis  is  not  prevalent.  During  times 
of  increased  incidence  these  primary  injections 
might  well  be  limited  to  the  first  6 months  of  life. 

3.  Routine  booster  injections  should  not  be 
given  when  poliomyelitis  is  prevalent  unless,  in 
the  opinion  of  the  physician,  there  is  danger  of 
acquiring  these  infections  in  the  absence  of  a 
booster  dose. 

4.  Immunizations  of  all  types  may  be  given 
during  epidemics  of  such  diseases,  or  to  persons 
leaving  the  country,  as  required  by  law  or  inter- 
national health  regulations. 

5.  There  is  no  contraindication  to  insulin  ther- 
apy and  desensitization  against  hay  fever, 
asthma,  and  other  allergic  diseases. 

6.  Injections  of  antibiotics  and  other  thera- 
peutic agents  should  be  given  whenever  indicated 
clinically. 

Smallpox 

Smallpox  vaccination  should  be  performed 
during  the  first  year  of  life,  since  at  this  age 
complications  are  infrequent.  It  is  perhaps  ad- 
vantageous to  complete  tetanus  immunization 
prior  to  vaccination  in  order  to  obviate  the  re- 
mote possibility  of  the  development  of  tetanus 
as  a complication.  It  is  best  to  avoid  the  pro- 
cedure in  the  summer  months  because  of  the 


prevalence  of  heat  rashes  and  other  skin  irrita- 
tions. Revaccination  should  be  performed  every 
5 to  7 years. 

The  calf  lymph  virus  is  introduced  by  the 
multiple  pressure  method,  and  the  site  of  inocu- 
lation is  generally  the  upper  left  arm  at  about  the 
point  of  insertion  of  the  deltoid  muscle,  the  skin 
having  previously  been  cleaned  either  with  ether 
or  acetone.  .Although  it  is  thought  that  the  use  of 
the  thigh  for  vaccination  predisposes  to  second- 
ary infection  and  larger  scars,  there  is  no  particu- 
lar contraindication  to  vaccination  almost  any- 
where on  the  body. 

The  vaccination  vesicle  should  be  left  exposed 
but  may  be  covered  by  a light,  loose  dressing. 
The  dressing  is  most  valuable  when  the  vaccina- 
tion is  performed  on  the  thigh,  since  it  protects 
the  vesicle  against  rubbing  by  the  diaper  or  other 
underclothing.  .A  tough  eschar  may  be  formed  by 
painting  the  vesicle  as  soon  as  it  is  visible  with 
a 3 per  cent  solution  of  picric  acid  in  alcohol. 
Several  applications  may  be  required,  but  the 
material  should  be  used  in  moderation  since 
picric  acid  may  cause  its  own  vesiculation  if 
used  too  heavily. 

With  a properly  performed  vaccination  one 
should  obtain  either  a primary  vaccinia,  an  ac- 
celerated “take,”  or  an  early  or  immediate  reac- 
tion. .Absence  of  any  reaction  at  the  site  of  inocu- 
lation generally  indicates  that  the  vaccine  virus 
was  inactive  at  the  time  of  its  use. 

Eczema  and  other  generalized  skin  eruptions 
in  the  patient  or  in  a member  of  the  household 
are  a definite  contraindication  to  vaccination. 
The  generalized  vaccinia  which  may  result  is  a 
potentially  fatal  complication  and  is  still  seen 
regularly  on  the  wards  of  children’s  hospitals. 

Typhoid 

'I'yphoid  vaccine  is  not  normally  included  in 
routine  immunization  procedures,  but  is  given 
only  when  indication  exists,  either  because  of 
specific  local  conditions  or  the  necessity  of  travel 
in  endemic  areas.  'Fhe  standard  trijile  tyjihoid 
vaccine  is  used,  and  children  receive  a fourth  to 


142 


Immunization  Practices — Howard 


MARCH,  1952 


a half  the  adult  close.  Boosters  are  required  every 
3 years  to  maintain  effectiveness. 

Influenza 

Influenza  virus  vaccine  has  been  used  in 
several  experimental  studies  in  the  past  few  years 
with  at  least  encouraging  results.  One  difficulty 
in  the  use  of  influenza  vaccine  is  the  occasional 
appearance  of  an  epidemic  due  to  an  antigen- 
ically  different  strain  from  those  present  in  avail- 
able commercial  vaccines.  Also,  protection 
against  Type  B influenza  afforded  by  the  vaccine 
is  better  than  that  against  Type  A infections. 
Therefore,  the  vaccine  is  best  used  when  it  is 
known  that  an  epidemic  is  in  progress  and  should 
not  be  recommended  for  routine  use. 

The  adult  dose  of  the  vaccine  is  a single  in- 
jection of  1 c.c.  Children  over  6 years  of  age  may 
receive  the  adult  dose;  those  under  6 years  are 
given  0.5  c.c.  The  amount  may  be  given  in  a 
single  dose  or  in  2 injections  3 to  7 days  apart. 
The  immunity  conferred  reaches  its  peak  within 
3 weeks,  and  then  tends  to  decrease  somewhat, 
although  adequate  protection  is  probably  present 
for  as  long  as  6 to  9 months.  The  vaccine  must  be 
repeated  each  year  in  order  to  maintain  effec- 
tiveness. It  is  not  clear  to  what  extent  these 
additional  injections  act  as  recall  or  stimulating 
doses. 

Influenza  vaccine  has  been  responsible  for  oc- 
casional systemic  reactions,  largely  febrile  in  na- 
ture, though  possibly  resembling  a mild  attack  of 
the  disease.  These  reactions  are  directly  related 
to  the  quantity  of  virus  given,  and,  therefore,  if 
reactions  are  suspected  or  feared,  the  divided 
dose  technic  should  be  used.  Since  the  vaccine  is 
prepared  from  infected  chick  allantoic  fluid  there 
is  always  the  possibility  of  its  injection  producing 
an  allergic  reaction  in  the  egg-sensitive  indi- 
vidual. A proper  history  would  seem  to  be  suffl- 
cient  safeguard  in  most  instances,  but  where 
doubt  exists  a skin  sensitivity  test  may  be  per- 
formed, 0.02  c.c.  of  a 1:10  dilution  of  the  vaccine 
being  used.  Use  of  the  vaccine  should  be  omitted 
if  there  is  any  evidence  of  sensitivity. 


Scarlet  Fever 

Immunization  against  scarlet  fever  is  still 
being  used  to  some  extent,  but  the  rationale  of 
its  employment  is  open  to  question.  The  point 
most  often  raised  is  in  relation  to  the  role  of  the 
streptococcus  toxin  versus  the  effects  of  the  strep- 
tococcus itself  in  scarlet  fever  and  streptococcus 
sore  throat  without  a rash.  If  the  immunity  is 
effective  only  against  the  toxin,  a false  sense  of 
security  is  developed  which  is  unwarranted  in 
view  of  the  many  difficulties  encountered  with 
the  purely  bacterial  phases  of  streptococcal  in- 
fections. In  addition,  Dick  toxin,  which  is  still 
the  material  of  choice  for  immunization,  produces 
many  severe  reactions.  The  effectiveness  of  the 
antibiotics  would  seem  to  eliminate  the  last  need 
for  protection  against  scarlet  fever. 

Tuberculosis 

I cannot  close  without  brief  mention  of  one 
highly  controversial  immunologic  procedure,  the 
use  of  BCG  vaccine  in  the  control  of  tuberculo- 
sis. 

BCG  vaccine  (bacillus  of  Calmette  and  Gue- 
rin) is  an  attenuated  viable  strain  of  bovine 
tubercle  bacillus  capable  of  producing  a com- 
pletely benign  primary  infection  when  properly 
inoculated  into  the  human.  Its  primary  purpose 
is  to  prevent  the  development  of  naturally  oc- 
curring primary  infections,  especially  among 
those  groups  of  individuals  most  apt  to  be  ex- 
posed. In  addition  it  eliminates  the  possibility  of  , 
development  of  the  complications  of  such  pri- 
mary infections,  including  tuberculous  meningitis,  I 
miliary  tuberculosis,  and  tuberculous  pneumonia,  j 
On  the  other  hand,  the  patient  so  protected  is  i 
rendered  allergic  or  hypersensitive  to  tuberculo-  ' 
protein  and,  like  the  person  recovering  from  a ( 
natural  primary  infection,  is  liable  to  the  hazards  ^ 
of  the  reinfection  t^pe  of  tuberculosis.  There 
remains  the  question  of  which  is  the  greater  I 
danger,  the  occurrence  of  a naturally  acquired  j 
primary  infection  in  the  tuberculin-negative  in-  | 
dividual,  or  the  hazard  from  reinfection  forms  . 
which  can  only  appear  after  the  development  of  | 


VOL.  XXI,  NO.  3 


Medical  Annals  of  the  District  of  Columbia 


143 


tuberculin  sensitivity.  Although  it  is  impossible 
to  answer  this  question  accurately,  the  impres- 
sion is  growing  that  among  infants,  children,  and 
young  adults  the  naturally  acquired  primary 
infection  is  much  the  greater  menace. 

At  the  present  time  the  vaccine  is  being  used 
only  under  controlled  conditions  in  groups  occu- 
pationally exposed,  or  in  selected  population 
groups  with  high  tuberculosis  morbidity  and 
mortality  rates.  There  is  much  opposition  to  the 
vaccine  from  many  authorities  on  tuberculosis, 
and  the  final  decision  as  to  its  value  will  not  be 
known  for  some  time. 

Summary 

In  summary,  the  following  immunization 
schedules  are  recommended. 


IMMUNIZATION  SCHEDULES 


Immunization  program  recommended  by  the  Sub- 
committee on  Child  Welfare  of  The  Medical  Society 
of  the  District  of  Columbia 

3 Months  0.5  c.c.  .Mum-precipitated  or 

aluminum  hydro.xide-  ad- 
sorbed diphtheria  and  tet- 
anus toxoids  with  pertussis 
vaccine,  30  billion  organ- 
isms/c.c. 

4 Months  0.5  c.c.  Triple  toxoid  as  above 

5 Months  0.5  c.c.  Triple  toxoid  as  above 


*6  Months 
7-12  Months 
12  Months 
18  Months 


II.  Routine  for  Schick 
Miller!) 

4-8  Weeks 
8-12  Weeks 
20-24  Weeks 
6-12  Months 
12  Months 
18  Months 


III.  Routine  for  Schick- 
Miller') 


0.5  c.c.  Triple  toxoid  as  above 
Smallpox  vaccination 
Schick  test  and  tuberculin  test 
0.5  c.c.  Triple  toxoid,  booster, 
as  above.  Additional  boost- 
ers at  4 and  6 years, 
■positive  mothers  (adapted  from 

0.5  c.c.  Triple  toxoid  as  above 
0.5  c.c.  Triple  toxoid  as  above 
0.5  c.c.  Triple  toxoid  as  above 
Smallpox  vaccination 
Schick  test  and  tuberculin  test 
0.5  c.c.  Triple  toxoid,  booster, 
as  above.  Additional  boost- 
ers at  4 and  7 years, 
negative  mothers  (adapted  from 


1 Month 

0.5  c.c.  .Alum-precipitated  or 
aluminum  hydroxide-ad- 
sorbed  pertussis  vaccine 

2 Months 

0.5  c.c.  Pertussis  vaccine,  as 
above 

5 Months 

0.5  c.c.  Triple  toxoid  as  above 

7 Months 

0.5  c.c.  Triple  toxoid  as  above 

10  Months 

0.5  c.c.  Triple  toxoid  as  above 

11-16  Months 

Smallpox  vaccination,  tubercu- 
lin test  and  Schick  test 

18  Months 

0.5  c.c.  Triple  toxoid,  booster, 
as  above.  .Additional  boost- 
ers at  4 and  7 years. 

* This  fourth  dose  is  not  recommended  by  the  Commit- 
tee on  Immunizations  of  The  American  .Academy  of  Pediatrics. 

‘Miller,  J.  J.,  Jr.,  and  others;  Immunology  in  practice 
of  pediatrics.  Pediatrics,  1951,  7,  118. 


MANAGEMENT  OF  HEMORRHAGE  IN  THE  NOSE 
AND  THROAT 

ALGER  B.  DOLAND,  M.D. 

W ashinglon 


management  of  hemorrhage  in  the 

(y  nose  and  throat  should  follow  a regular, 
complete  regime  of  correct  local  therapy  com- 
bined with  fully  adequate  systemic  measures  to 
control  and  insure  maintenance  of  hemostasis. 
Postoperative  hemorrhage  following  tonsillec- 
tomy is  not  infrequent.  Nasal  hemorrhage  occurs 
in  many  physiologic  and  pathologic  states.  In- 
flammation, trauma,  circulatory  disease,  acute 
infectious  fevers,  blood  dyscrasias,  vitamin  C 
deficiency,  and  new  growths  may  manifest  them- 
selves by  nasal  hemorrhage.  The  mechanism  of 
epistaxis  is  erosion  of  a superficial  arteriole.  W hen 
a venule  breaks,  blood  soon  clots  and  nasal 
hemorrhage  is  not  observed.  The  anterior  car- 
tilaginous septum,  Kiesselbach’s  area,  is  the  site 
of  most  bleeding  in  the  nose.  Repeated  septal 
bleeding  leads  to  crusting,  loss  of  mucosa,  and 
perforation  of  cartilage. 

Local  Therapy 

Visualization  of  the  source  of  hemorrhage  is 
essential.  This  necessitates  proper  lighting,  which 
is  best  supplied  by  a head  mirror  or  head  light. 
Both  hands  are  thus  left  free  to  manage  the  local 
problem.  bloodless  field  can  be  obtained  by  the 
aid  of  a suction  machine  with  apiwopriate  tip. 
For  pain,  2 per  cent  pontocaine  applied  on  cotton 
is  indicated.  Thus  discomfort  during  local  pro- 
cedures largely  will  be  eliminated.  Neosynephrine 
1:100  or  adrenalin  1:1000  on  a cotton  sponge 
applied  to  the  bleeding  area  will  induce  prompt 
clotting.  If  hemostasis  is  effected  without  diffi- 
culty, prompt  cauterization  will  do  much  to 
eliminate  recurrence.  Electrocauterization  is  as 
satisfactory  as  the  use  of  silver  nitrate  or  tri- 
chloracetic acid.  When  bleeding  in  the  nose  can- 


not be  controlled,  the  use  of  vaseline  gauze  or 
oxidized  cellulose  may  be  of  value.  If  hemorrhage 
is  severe  a postnasal  pack  is  used.  The  pack 
should  be  cut  and  shaped  according  to  the  size 
of  the  nasopharynx.  An  ill-fitting  pack  will  not 
stay  in  place,  and  blood  will  trickle  down  the 
throat.  After  the  pack  is  shaped,  a strong  silk 
suture  is  tied  around  it,  leaving  2 long  ends. 
Next  a catheter  is  inserted  in  the  nose  and  its 
tip  passed  through  the  nasopharynx  and  out  into 
the  mouth.  One  end  of  the  suture  attached  to 
the  pack  is  tied  to  the  catheter  tip.  The  catheter 
and  tie  are  drawn  out  of  the  nose.  The  pack  is 
fitted  tightly  into  place  in  the  nasopharynx.  The 
pack’s  ties  are  secured  over  a cotton  roll  placed 
on  the  upper  lip.  An  anterior  nasal  pack  can  be 
inserted  through  the  nasal  entrance  to  close  one 
side  of  the  nose  completely.  An  expansible  rubber 
catheter  may  be  substituted  for  the  posterior 
gauze  pack.  Restlessness  and  the  increased  phys- 
ical activity  accompanying  hemorrhage  make 
the  possibility  of  recurrence  greater.  If  intra- 
nasal and  systemic  measures  do  not  stop  bleed- 
ing, one  of  the  large  posterior  nasal  vessels  may 
have  to  be  ligated.  In  order  to  ligate  a postnasal 
vessel,  submucous  resection  usually  must  be  done. 
If  the  septum  has  a large  defect,  it  should  be 
corrected  promptly.  Occasionally  it  is  necessary 
to  occlude  the  external  carotid  or  the  internal 
maxillary  artery.  In  case  of  great  emergency  the 
blood  flow  to  the  head  can  be  reduced  by  direct 
pressure  on  l)oth  external  carotid  arteries  until  a 
sponge  can  be  placed  over  the  area  of  hem- 
orrhage. .\fter  epistaxis  is  controlled,  its  cause 
should  be  determined  and  treated  promptly  in 
order  to  prevent  recurrence. 

In  bleeding  following  tonsillectomy  it  is  desir- 
able to  avoid  the  use  of  a second  general  anes- 


144 


VOL.  XXI,  NO.  3 


Medical  Annah  of  the  District  of  Columbia 


145 


thetic.  Topical  or  local  anesthesia  will  eliminate 
pain  during  local  therapy.  A medicated  sponge 
applied  to  a tonsillar  fossa  should  be  left  in  place 
long  enough  to  allow  clotting.  If  bleeding  is 
slight  a gelatin  sponge  may  be  placed  over  the 
area  of  hemorrhage  and  left  until  it  dissolves.  It 
cannot  be  too  strongly  emphasized  that  gentle- 
ness is  most  important  in  dealing  with  a patient 
with  nasopharyngeal  bleeding.  It  is  surprising 
how  much  work  one  can  do  on  a very  small 
child  if  he  gains  the  patient’s  confidence  through 
gentleness. 

Systemic  Therapy 

Adequate  systemic  therapy  is  of  paramount 
importance  in  the  control  of  hemorrhage  in  the 
nose  and  throat.  Activity  should  be  limited  for 
at  least  24  hours.  Bed  rest  is  not  indicated  when 
bleeding  is  slight  and  cauterization  effective. 
Sedation  is  important  to  combat  anxiety  and 
must  be  administered  in  a form  which  will  be 
promptly  assimilated.  Intramuscular  administra- 
tion is  preferable  to  the  giving  of  a tablet,  which 
is  painful  when  swallowed.  Moderate  doses  of  a 
barbiturate  in  small  children  are  useful.  Mor- 
phine and  atropine  are  an  excellent  combination 
or  adults,  as  well  as  demerol.  Synthetic  vitamin 


K helps  control  hemorrhage  in  the  nasopharynx 
if  the  prothrombin  time  is  found  to  be  prolonged. 
If  bleeding  is  great  an  initial  dose  of  72  mg.  of 
menadione  sodium  bisulfite  intravenously  will 
aid  in  controlling  it.  Ten  milligrams  of  synthetic 
vitamin  K intramuscularly  every  4 hours  is  a 
deterrent  to  recurrent  hemorrhage.  Small  doses 
of  vitamin  K or  large  doses  given  at  irregular 
intervals  are  not  satisfactory.  In  cases  of  pro- 
found hemorrhage,  whole  blood  is  given  im- 
mediately upon  completion  of  local  therapy. 

Summary 

Local  management  of  hemorrhage  in  the  nose 
consists  of  obtaining  a bloodless  field  and  treating 
the  area  of  hemorrhage  at  once  by  cauterization 
if  possible;  otherwise  nasal  packs  are  used  to 
stop  bleeding.  Cauterization  is  used  to  close  a 
small  vessel  in  the  throat.  Larger  vessels  must 
usually  be  ligated  under  local  anesthesia.  Im- 
mediately following  local  therapy  a regular  re- 
gime of  sedation,  vitamin  K and  other  systemic 
measures  as  outlined  must  be  instituted  to  pre- 
vent further  hemorrhage.  Recurrent  bleeding 
may  be  prevented  if  the  physician  remains  with 
the  patient  long  enough  to  see  that  supportive 
measures  have  been  instituted. 


PILONIDAL  CYSTS*t 
Review  of  115  Cases 


DUANE  C.  RICHTMEYER,  M.D. 

Clinical  Instructor  in  Surgery,  George  Washington  University 
School  of  Medicine 


^ ^ IVE  years  ago  I presented  before 

this  staff  meeting  a report  on  all  the  pilonidal 
cysts  done  in  Doctors  Hospital  between  March 
5,  1941  and  March  5,  1946.  This  present  report 
covers  the  period  from  March  1946  to  March 
1951.  Both  of  these  reports  required  considerable 
cooperation  between  the  Record  Room,  repre- 
sented by  Miss  Holt,  various  surgeons,  and  my- 
self. I want  to  e.xpress  my  thanks  to  all  those  who 
so  kindly  lent  their  aid  to  this  study. 

At  the  conclusion  of  the  previous  report  1 made 
the  following  observations  and  recommenda- 
tions: 

1 . The  care  of  a pilonidal  cyst  is  very  apt  to  be 
a long-drawnout  affair. 

2.  Some  method  of  primary  closure  cuts  down 
on  the  period  of  convalescence.  Special  attention 
was  at  that  time  drawn  to  the  method  by  which 
the  gluteus  fascia  was  separated  from  the  sacrum 
and  resutured  in  the  midline. 

3.  The  length  of  stay  in  the  hospital  does  not 
seem  to  materially  influence  the  time  it  takes  the 
wound  after  e.xcision  of  the  cyst  to  heal. 

4.  The  number  of  office  visits  is,  on  the  whole, 
less  with  primary  closure  than  with  drainage. 

5.  The  removal  of  a pilonidal  cyst  can  be  safely 
combined  with  other  operative  procedures  on 
carefully  selected  cases. 

Hospital  Incidence 

The  pilonidal  cyst  occupies  a small  percentage 
of  the  total  hospital  admissions,  there  being  210 
pilonidal  cyst  admissions  out  of  about  110,000 

* From  the  Departments  of  Surgery  of  Doctors  Hospital 
and  the  George  Washington  University  School  of  Medicine. 

t Read  before  the  meeting  of  the  Surgical  Staff  of  Doctors 
Hospital,  June  18,  1951. 


hospital  admissions,  or  about  0.2  per  cent.  How- 
ever, these  patients  with  their  illness  are  quite 
uncomfortable,  inconvenienced,  and  at  times  dis- 
abled for  a long  time.  At  present  there  is  still  a 
fairly  high  recurrence  rate,  there  being  operations 
on  10  recurrent  pilonidal  cysts  in  this  series.  We 
are  endeavoring  to  find  and  advocate  a method 
of  doing  them  which  will  reduce  this  incidence  of 
recurrence.  Many  of  these  patients  have  a more 
than  average  number  of  office  visits.  Methods 
which  reduce  these  are  certainly  economically 
sound. 

Number  of  Patients 

The  present  study  consisted  of  all  the  pilonidal 
cysts  done  from  March,  1946  through  March, 
1951  in  Doctors  Hospital.  These  operations  to- 
taled 1 15  on  113  patients.  There  were  43  surgeons 
who  operated  in  this  series.  Breaking  down  the 
work  done  by  the  various  surgeons,  20  physicians 
did  1 pilonidal  cyst  each  on  20  patients,  10  did 
2 each,  5 did  3 each,  2 did  4 each,  3 did  5 each,  1 
did  8,  1 did  9,  and  1 did  20. 

From  March,  1946  to  January  1,  1947,  21 
pilonidal  cysts  were  done.  In  1947,  23  pilonidal 
cysts  were  treated  surgically;  in  1948,  17,  in 
1949,  22,  in  1950,  29,  and  from  January  1,  1951  to 
March  15,  1951,  3. 

History  of  the  Cases 

A history  was  available  on  the  chart  on  all  115 
of  these  patients.  From  this  we  glean  the  follow- 
ing information:  There  were  14  identifiable  chief 
complaints.  In  58,  or  50  per  cent  of  the 
patients,  drainage  was  one  of  the  chief  com- 
plaints. The  next  most  common  chief  complaint 
was  pain,  occurring  in  36,  or  31.5  per  cent. 


146 


VOL.  XXI,  NO.  3 


Medical  Annals  of  the  District  of  Columbia 


147 


Eighteen  patients,  or  15.6  per  cent,  complained 
of  tenderness,  and  18  patients  (15.6  per  cent) 
complained  of  a lump.  Seventeen  patients,  or 
14.7  per  cent,  stated  on  admission  that  they  had 
a cyst  at  the  base  of  the  spine.  There  were  8 
patients,  or  6.8  per  cent,  who  had  a definite 
history  of  injury  at  the  base  of  the  spine.  Six 
patients  were  recorded  as  having  more  than  1 
incision  and  drainage.  The  probability  is  that  a 
more  searching  study  of  the  history  would  reveal 
that  more  than  this  number  had  had  more  than 
1 incision  and  drainage  of  a cyst  before  consent- 
ing to  remedial  surgery. 

Four  patients  were  symptomless,  and  their 
pilonidal  cysts  were  discovered  on  examination 
and  operation  advised  and  done.  This  is  per 
cent  of  the  total.  Two  patients  complained  of 
itching  or  pruritus  in  the  region  of  the  pilonidal 
cyst.  One  each  complained  of  discomfort  on  sit- 
ting, backache,  and  difficulty  on  voiding.  There 
was  1 painful  pilonidal  scar.  This  should  not  be 
considered  a recurrence  of  the  cyst  but  one  of 
the  defects  of  the  operation.  It  is  my  belief  that 
more  than  this  1 patient  in  the  series  had  a pain- 
ful scar  for  a considerable  length  of  time,  al- 
though this  is  the  only  1 recorded  as  having  a 
removal  for  this  reason. 

Ten  of  these  operations,  or  8.7  per  cent,  were 
done  for  recurrence  of  a pilonidal  cyst.  One  of 
these  had  2 operations  in  this  hospital  a year 
apart.  Another  had  had  an  operation  7 years 
previously  in  this  hospital  and  had  a recurrence 
on  this  admission.  The  other  8 had  presumably 
been  operated  upon  elsewhere  and  had  come  to 
this  hospital  for  operative  removal  of  their  re- 
current pilonidal  cyst.  Eight  of  these  patients 
had  their  second  operation  for  a recurrent  pilo- 
nidal cyst  done  in  this  hospital.  One  of  these 
patients  had  his  fourth  operation  for  recurrent  pi- 
lonidal cyst  done  during  this  series.  Another  had 
his  third  operation  done  because  of  recurrence. 

Analysis  of  Recurrences 

A study  of  the  history  in  the  cases  of  recurrent 
pilonidal  cysts  shows  that: 


1.  One  patient  was  operated  on  in  1946,  1948, 
and  in  1950.  He  had  an  excision  and  packing.  It 
took  56  days  and  16  office  visits  for  healing,  and 
there  has  been  no  further  recurrence. 

2.  A recurrent  pilonidal  cyst  which  had  been 
opened  4 times  in  6 years  was  removed  and 
closed  with  a drain.  It  took  15  days  and  3 office 
visits  for  healing. 

3.  A man  aged  24  had  trouble  with  pilonidal 
pain  in  1944.  The  first  removal  was  in  January, 
1945,  the  second  in  March,  1945,  the  third  in 
August,  1945,  and  the  fourth  in  the  present 
series  in  November,  1950.  He  had  the  skin  edges 
sutured  to  the  fascia.  It  took  73  days  and  12 
office  visits  to  heal. 

4.  A fourth  patient  had  his  cyst  excised  2 
times  in  1942,  and  it  recurred  in  1949.  The  cyst 
was  excised  and  the  skin  edges  sutured  to  the 
fascia.  It  took  26  days  and  5 office  visits  for  heal- 
ing. 

5.  Another  man  had  an  operation  on  his  cyst 
3 months  before  the  present  excision,  with  partial 
suture  and  packing.  It  took  36  days  and  8 office 
visits  for  healing. 

6.  A woman  had  a removal  in  1946  with  dis- 
charge off  and  on  afterwards.  The  cyst  was 
removed  in  1949  and  the  gluteus  fascia  approxi- 
mated in  the  midline.  It  took  76  days  and  3 office 
visits  for  healing. 

7.  A man  had  recurrent  drainage  since  an 
operation  in  1934.  The  cyst  was  removed  and 
packed  open.  Healing  took  place  in  131  days  and 
17  office  visits. 

8.  A woman  had  an  original  operation  in  1940, 
with  recurrence  in  1947.  The  cyst  was  then  re- 
moved and  the  wound  packed  open.  She  was  well 
after  43  days  and  5 office  visits. 

9.  A man  had  his  first  operation  in  1942  with 
a primary  closure.  The  cyst  recurred  in  1946  and 
was  removed  and  left  open  in  1947.  It  took  129 
days  and  16  office  visits  for  healing. 

10.  A woman  had  her  pilonidal  cyst  excised 
in  1939,  with  recurrence  in  1945  and  removal  in 
1946  with  primary  suture  with  a drain.  It  took 
17  days  and  3 office  visits  for  healing. 


148 


Pilonidal  Cysts — Richimeyer 


MARCH,  1952 


Age 

A study  of  the  age  of  the  patients  done  in  this 
series  showed  that  the  youngest  were  3 girls 
aged  15.  The  oldest  was  a woman  aged  65.  By 
decades  there  were  19  patients  in  the  second 
decade,  61  in  the  third,  26  in  the  fourth,  6 in  the 
fifth,  and  2 in  the  sixth.  There  was  1 in  the 
seventh  decade.  The  average  age  was  27.1  years. 
This  compares  with  an  average  age  in  the  pre- 
vious series  of  28.1  based  on  the  known  ages  of 
92  patients. 

Sex 

A study  of  the  sex  of  these  patients  shows  that 
75  were  males  and  40  females.  This  compares 
with  60  males  in  the  previous  series  and  35 
females.  From  210  cases  in  which  the  sex  was 
known  in  both  of  these  series  there  were  135  or 
64.5  per  cent  males  and  75  or  35.5  per  cent 
females. 

Types  of  Operations 

In  the  previous  study  we  soon  found  that  there 
were  9 well  identifiable  methods  of  treating  the 
pilonidal  cyst.  In  the  present  study  8 methods 
could  be  identified.  The  various  methods  of  treat- 
ing the  pilonidal  cyst  are  briefly  enumerated  as 
follows: 

1.  Simple  excision  and  packing  (13  cases). 

2.  Partial  excision  and  curettage  of  the  tract. 
(This  method  did  not  appear  in  the  series  from 
1946  to  1951.) 

3.  Cyst  excised  and  sutured  with  a Penrose 
drain  (3  cases).  (This  is  a form  of  primary 
closure.) 

4.  Cyst  excised  and  the  edges  sutured  to  the 
fascia  (33  cases). 

5.  Cyst  excised  and  the  wound  closed  (46 
cases) . 

6.  Excision  of  the  cyst,  partial  suture  and 
packing  (4  cases). 

7.  Excision  of  the  cyst,  edges  undercut  and 
sutured  (1  case). 

8.  Cyst  excised,  the  gluteus  fascia  divided  and 


sutured  in  the  midline  (12  cases).  Those  sutured 
with  or  without  a drain  were  included  in  this 
method. 

9.  Simple  incision  and  drainage  (3  cases). 

A great  many  of  the  cysts  in  this  present  series 
had  had  incision  and  drainage  in  the  doctor’s 
office  shortly  before  being  admitted  to  the  hos- 
pital. Those  done  in  the  doctor’s  office  were  not 
included  in  the  operations  done  in  this  series.  The 
incisions  and  drainages  done  in  the  hospital  were 
included  in  the  operations  done  in  this  series.  The 
type  of  excision  could  not  be  made  out  from  the 
operative  record  in  2 of  the  cases.  The  surgeons 
supplied  this  information. 

There  was  1 recurrence  in  group  4.  Of  the  3 
patients  who  had  simple  incision  and  drainage, 
1 was  classified  as  a recurrence  in  this  series,  and 
the  cyst  was  removed  1 year  later.  The  other  2 
had  no  further  trouble  during  the  period  covered 
by  this  study. 

Concomitant  Surgical  Procedures 

Eleven  of  these  patients  or  9.6  per  cent  had 
other  operations  done  at  the  same  time  that  their 
pilonidal  cyst  was  removed.  Three  of  these  pa- 
tients had  a hemorrhoidectomy.  One  had  an 
anal  fissure  removed,  1 had  a sebaceous  cyst 
removed  from  the  face,  another  had  an  appen- 
dectomy and  removal  of  a thrombosed  hemor- 
rhoid, 2 had  anal  fistulae  excised,  1 had  a lipoma 
removed  from  the  leg,  1 had  the  labia  minora 
removed,  and  1 had  cauterization  of  the  cervix. 
None  of  these  operations  seemed  to  seriously 
complicate  the  pilonidal  cyst  removal  as  could 
be  judged  from  the  chart. 

.Anesthesia 

.Anesthesia  records  were  given  on  114  of  the 
115  charts.  The  most  popular  anesthetic  used 
(92  patients)  was  sodium  pentothal  intrave- 
nously supplemented  by  ethylene-oxygen  gas  mix- 
ture. This  was  used  in  80  per  cent  of  the  total 
number  of  anesthetics.  Spinal  anesthesia  was 
used  in  7 of  these  patients  or  6.1  per  cent. 


VOL.  XXI,  NO.  3 


Medical  Annals  of  the  District  of  Columbia 


149 


Spinal  anesthesia  supplemented  by  sodium  pen- 
tothal  intravenously  was  used  in  3 cases  or  2.6 
per  cent.  Ethylene  and  o.xygen  as  a sole  anes- 
thetic agent  was  used  in  3 patients  or  2.6  per  cent. 
Two  patients  each  had  avertin,  sodium  pentothal, 
gas,  ether  anesthesia,  and  sodium  pentothal-gas 
curare  anesthesia.  One  patient  had  her  cyst  re- 
moved and  sutured  primarily  under  1 per  cent 
novocaine.  One  patient  had  a pilonidal  abscess 
opened  under  ethyl  chloride  locally.  One  patient 
had  spinal  anesthesia  plus  intravenous  nembutal 
anesthesia. 

Antibiotics 

Antibiotics  were  not  in  use  in  the  previous 
series.  During  this  series  antibiotics  came  into 
use,  and  in  1946  3 of  the  21  patients  or  14.2  per 
cent  received  them  in  one  form  or  other.  In  1947 
5 of  23  cases  or  21.6  per  cent  received  antibiotics. 
In  1948  8 or  47  per  cent  of  1 7 cases  received  them. 
In  1949  8 or  36  per  cent  of  22  cases  received  them. 
In  1950  8 of  29  cases  or  27.5  per  cent  received 
antibiotics.  All  3 patients  treated  during  the 
first  3 months  of  1951  received  antibiotics. 

The  most  popular  antibiotic  was  penicillin. 
Sulfadiazine  was  used.  Tyrothrycin  dressings 
were  used  on  1 patient  in  1947,  and  streptomycin 
was  used  in  2 cases  in  1950. 

In  the  latter  years  of  this  study  penicillin  dos- 
age was  increased  considerably  over  that  in  the 
early  years.  The  percentage  of  patients  receiving 
antibiotics,  aside  from  1946  and  1947  when  they 
were  fairly  expensive,  has  not  increased  very 
much  in  the  last  4 years.  The  antibiotics  in  most 
cases  were  used  prophylactically  to  cut  down  on 
the  incidence  of  postoperative  wound  infection, 
and  I believe  that,  in  the  cases  sutured  in  ex- 
pectance of  primary  union,  their  use  contributed 
to  a successful  outcome. 

Length  of  Hospital  Stay 

These  115  patients  stayed  in  the  hospital  a 
total  of  809  days,  or  an  average  of  7.07  days  per 
patient.  Breaking  this  down  we  see  that  no  pa- 


tient stayed  only  1 day.  Four  patients  stayed  2 
days,  4 patients  3 days,  15  patients  4 days,  15 
patients  5 days,  19  patients  6 days,  16  patients 
7 days,  16  patients  8 days,  5 patients  9 days,  6 
patients  10  days,  4 patients  11  days,  5 patients 
14  days,  1 patient  17  days,  and  1 patient  19 
days. 

Some  of  the  most  important  findings  in  this 
study  are  summarized  in  table  1.  In  this  chart 
is  correlated  the  type  of  excision  with  several 
different  factors.  In  this  series  of  115  patients 
there  were  62  who  had  a primary  closure  of  the 
pilonidal  cyst.  This  was  54  per  cent  of  the  total 
in  this  series  of  115.  In  the  previous  series  of 
patients  done  from  1941  to  1946  only  30  per  cent 
had  a primary  closure  of  the  pilonidal  cyst. 

Correlated  with  the  average  hospital  days  we 
see  that  the  eighth  method  of  excision  with  the 
gluteus  fascia  divided  and  sutured  in  the  midline 
had  the  longest  hospital  stay,  an  average  of  8.9 
days.  The  average  hospital  stay  decreased  in 
this  order:  partial  suture  and  packing,  excision 
and  closure  of  the  wound,  excision  and  the  edges 
sutured  to  the  fascia,  excision  and  the  wound 
closed  with  a drain,  simple  excision  and  packing, 
excision  and  edges  undercut  and  sutured,  and 
incision  and  drainage.  Incision  and  drainage  had 
a surprising  average  of  4.3  days  in  the  hospital. 

The  shortest  hospital  stay  in  this  series  was 
2 days  in  the  case  of  1 of  the  patients  who  had 
simple  excision  and  packing  of  the  wound.  The 
longest  hospital  stay  in  this  series  was  19  days 
and  occurred  in  a case  in  which  the  cyst  was 
excised  and  the  edges  of  the  wound  sutured  to 
the  fascia. 

The  average  days  of  convalescence  were 
figured  from  the  date  the  cyst  was  excised  until 
the  wound  was  reported  healed  by  the  surgeon 
in  charge.  This  date  was  obtained  from  the  sur- 
geon by  reference  to  his  office  records  and  was 
very  willingly  reported  by  all  the  surgeons  who 
operated  upon  the  patients  in  this  series.  The 
average  days  of  convalescence  were  66.8  for  11 
cases  of  simple  excision  and  packing.  Of  these 
the  longest  period  was  131  days  and  the  shortest 


150 


Pilonidal  Cysts — Richtnieyer 


MARCH,  1952 


TABLE  1 
Significant  Data 


1946-1951 

TYPE  OF  EXCISION 


1.  Simple  excision,  packing.  . . 

2.  Partial  excision,  curettage 

of  tract 

3.  Cyst  excised,  sutured  with 

a drain 

4.  Cyst  excised,  edges  sutured 

to  fascia 

5.  Cyst  excised,  wound 

closed 

6.  Excision,  partial  suture  and 

packing 

7.  Excision,  edges  undercut 

and  sutured 

8.  Excision,  gluteus  fascia  di- 

vided and  sutured  in  mid- 
line   

9.  Incision  and  drainage 

(Primary  closure  in  62  or  54%) 
Total  Number  of  0])- 
erations 

Penicillin-treated  patients 


TOTAL  NUM- 
BER OF 

PATIENTS 

AVERAGE 

HOSPITAL 

DAYS 

SHORT- 

EST 

HOS- 

PITAL 

STAY 

LONG- 

EST 

HOS- 

PITAL 

STAY 

AVERAGE 

DAYS  OF 
CONVA- 
LESCENCE 

LONGEST 

NUMBER 
OF  DAYS 
TO  HEAL 

SHORT- 
EST 
NUM- 
BER OF 

DAYS 

TO 

HEAL 

AVERAGE 

NUMBER 

OF  OFFICE 
VISITS 

GREAT- 
EST 
NUM- 
BER OF 
OFFICE 

VISITS 

LEAST 
NUM- 
BER OF 
OFFICE 

VISITS 

KNOWN 

RECUR- 

RENCES 

13 

5.6 

2 

10 

66.8 

131 

36 

11.3  1 

18 

2 

0 

(11 

cases) 

0 

— 

— 



— 

— 

— 

— 

— 

— 

3 

6.3 

5 

8 

16 

21 

12 

3 . 75 

4 

3 

0 

! 33 

7.06 

3 

19 

66.8 

333 

17 

8.5 

63 

2 

1 

(29 

cases) 

46 

7,13 

2 

17 

41.2 

201 

7 

4.8 

16 

1 

0 

4 

7.75 

5 

14 

54.3 

76 

36 

10.3 

13 

8 

0 

1 

5 

5 

5 

43 

3 

1 

i 

1 0 

12 

8.9 

6 

14 

50.4 

254 

; 15 

5 

' 25 

1 

1 1 

0 

(11 

cases) 

1 

; 3 

4.3 

4 

5 

60 

1 

20 

i 

i 1 

1 

(1 

i 

case) 

1 

1 

115 

1 

1 

Data  on 

1 

i 63 

32  of  34 

' 

! 

' 

■ 

36  days.  Of  the  33  cases  in  which  the  cyst  was 
excised  and  the  edges  sutured  to  the  fascia  there 
were  data  on  29  cases  in  which  I calculated  an 
average  of  66.8  days  of  convalescence.  This  in- 
cluded the  longest  number  of  days  to  heal  of  333 
and  the  shortest  of  17  done  by  this  method.  By 
excision  with  partial  suture  and  packing  there 
were  4 cases,  with  an  average  of  54.3  days  from 
operation  to  complete  healing.  The  longest  period 
was  76  days  and  the  shortest  36  days.  With  the 
method  of  excision  and  closure  by  dividing  the 
gluteus  fascia  and  suturing  it  in  the  midline 
there  were  12  cases  done  in  this  manner.  The 
average  days  of  convalescence  were  50.4,  with 
the  longest  254  days  and  the  shortest  15.  It 
took  43  days  for  the  pilonidal  cyst  wound  to 
heal  when  it  was  managed  by  excision  with 
undercutting  of  the  edges  and  primary  suture. 
When  the  cyst  was  excised  and  the  wound  closed 


primarily,  as  was  done  in  46  cases  in  this  series, 
the  average  days  of  convalescence  were  41.2, 
the  longest  being  201  and  the  shortest  7.  The 
best  record  in  this  series  was  on  those  in  which 
the  cyst  was  excised  and  sutured  with  a drain. 
This  was  done  in  3 cases.  The  average  days  of 
convalescence  were  16,  with  the  longest  21  and 
the  shortest  12. 

From  an  economic  point  of  view  it  is  interest- 
ing to  know  the  average  number  of  office  visits 
that  each  of  these  patients  made.  In  the  patients 
who  had  simple  excision  and  packing  the  average 
office  visits  were  11.3,  with  the  greatest  18  and 
the  least  2.  When  the  cyst  was  excised  and  su- 
tured with  a drain  the  average  office  visits  were 
3.75  with  the  greatest  4 and  the  least  3.  When  the 
cyst  was  excised  and  the  edges  sutured  to  the 
fascia  the  average  office  visits  were  5,  with  the 
greatest  number  63  and  the  least  2.  When  the 


VOL.  XXI,  NO.  3 


Medical  Annals  of  the  District  of  Columbia 


151 


cyst  was  excised  and  the  wound  closed  the  aver- 
age office  visits  were  4.8,  with  the  greatest  16 
and  the  least  1.  With  the  excision,  partial  suture 
and  packing  the  office  visits  averaged  10.3,  with 
the  greatest  13  and  the  least  8.  In  the  case  of  the 
cyst  which  had  its  edges  undercut  and  sutured 
there  were  3 office  visits.  In  the  most  complicated 
method  of  treatment  of  these  pilonidal  cysts, 
namely,  by  gluteus  fascia  division  and  suture  in 
the  midline,  the  average  office  visits  were  5,  with 
25  the  greatest  and  1 the  least.  The  patient  who 
was  reported  as  healing  after  an  incision  and 
drainage  had  20  office  visits.  One  sees  by  examin- 
ing these  figures  that  the  office  visits  necessary 
from  excision  to  complete  healing  is  much  less 
in  those  types  in  which  there  is  primary  suture  of 
the  wound. 

There  are  only  2 known  recurrences  in  this 
group  of  115  patients.  One  of  these  followed  an 
incision  and  drainage  and  in  my  opinion  was 
expected.  The  other  was  after  the  cyst  was  ex- 
cised and  the  edges  sutured  to  the  fascia.  This 
was  picked  up  because  he  was  operated  upon  the 
last  time  in  this  hospital  by  a different  surgeon. 
The  first  surgeon  had  no  knowledge  of  the  recur- 
rence. 

Summary  and  Conclusions 

There  were  no  deaths  in  this  series  of  115 
cases. 

Recovery  from  a pilonidal  cyst  operation  is 
apt  to  be  a long-drawnout  affair. 


Primary  closure  is  the  method  of  choice  in  this 
order : 

1 . Suture  with  a drain 

2.  Primary  suture  after  excision 

3.  Excision,  gluteus  maximus  fascial  dissection 
and  suture  in  the  midline.  This  method  seemed 
more  useful  in  the  more  complicated  cases.  In 
some  cases  the  sutures  were  left  in  longer  than 
the  7-  to  10-day  period. 

Antibiotics  should  be  used  in  cases  in  which 
infection  is  anticipated.  They  need  not  be  used 
in  all  cases.  The  use  of  antibiotics  could  not  be 
statistically  proved  to  shorten  the  length  of  con- 
valescence. Penicillin-treated  patients  took  an 
average  of  63  days  to  heal,  which  is  longer  than 
the  average  for  most  methods  of  closure. 

The  length  of  hospital  stay  does  not  seem  to 
materially  influence  the  time  it  takes  the  cyst  to 
get  well.  Office  visits  are  less  numerous  with  pri- 
mary closure. 

Pilonidal  cyst  removal  can  safely  be  combined 
with  other  operative  procedures  in  carefully  se- 
lected cases. 

Most  important,  recurrence  seems  to  be  less 
in  this  series  with  primary  closure  than  with  any 
open  method.  It  may  be  that  one  of  the  reasons 
for  recurrences  is  fascial  or  possibly  bony  infec- 
tion with  low-grade  osteomyelitis  or  fascitis  as  a 
result  of  leaving  the  wound  open. 

Primary  closure  was  done  in  54  per  cent  or 
62  of  the  115  cases  in  this  series  and  30  per  cent 
of  the  series  from  1941  to  1946. 


SOCIETY  AND  THE  PHYSICIAN 
IX,  The  Physician  and  His  Faith 


Faith  makes  the  world  go.  No  one  questions  whether  the  tides  will  follow  in  regular 
sequence,  whether  the  sun  will  come  up,  or  whether  the  seasons  will  come  in  proper  progression. 
W e know  they  will.  Nor  do  we  often  question  whether  a sound  bank  will  honor  our  check,  a 
good  store  allow  us  credit,  or  a properly  certified  note  be  paid.  We  have  developed  “faith” 
in  these  man-made  institutions  and  they  in  us. 

Faith  in  one’s  self  is  equally  important.  The  self-confident  man  accomplishes  much  be- 
cause he  has  the  courage  of  his  convictions.  On  the  contrary,  the  person  with  an  inferiority 
complex  is  unhappy  and  accomplishes  little.  He  has  no  faith  in  himself,  and  in  consequence 
has  no  faith  in  others,  or  vice  versa.  Self-faith  is  just  as  important  to  a well-run  individual  as 
faith  in  others  is  to  a well-run  world. 

Somehow,  though,  faith  in  one’s  self  is  like  pulling  yourself  up  by  your  own  bootstraps. 
It’s  impossible  to  accomplish  without  some  help.  Fortunately,  there  is  available  to  those  who 
wish,  a higher  intelligence  and  spirit,  a (lod  (called  by  many  names,  and  believed  in  variously 
in  different  races  and  individuals),  from  whom  we  can  expect  help  and  encouragement,  and 
to  whom  we  can  admit  failure.  It’s  rather  satisfying  to  know  that  help  is  available,  even  when 
we  don’t  think  we  need  it. 

d'he  most  useful  and  beloved  physicians  I know  are  men  who  have  faith  in  themselves, 
in  peoi)le  about  them,  and  in  a higher  source  of  power  and  information  than  themselves.  I 
would  have  little  faith  in  any  physician  who  thought  that  he  himself  was  the  final  authority. 

Sir  William  Osier  in  “A  Way  of  Life”  urges,  “Begin  the  day  with  Christ  and  His  Prayer” 
(p.  37),  and  suggests  that  the  Bible  “will  give  you  faith  in  your  day”  (p.  38).  Quite  a prescrip- 
tion from  one  of  the  medical  immortals! 


(^(m^efteKce  m *7ftedcc^l  ^ecAaCc^ 

SPONSORED  BY 

THE  MEDICAL  SOCIETY  OF  THE  DISTRICT  OF  COLUMBIA 
Friday  and  Saturday,  April  4 and  5,  1952 

ALL  SESSIONS  IN  THE  MEDICAL  SOCIETY’S  BUILDING  1718  M STREET,  N.W. 

PROGRAM 


FRIDAY  MORNING 

“The  Need  for  Teaching  the  Teachers” 
William  Parson,  M.D. 

Professor  of  Medicine,  University  of  Virginia 

“The  Importance  of  Selling  Knowledge” 

W.  C.  Davison 

Head,  Department  of  Education,  International 
Business  Machines 


FRIDAY  AFTERNOON, 

“Drawings  for  Lectures” 

Richard  H.  (“Dick”)  Mansfield 
Cartoonist,  Washington  Evening  Star,  creator  of 
“Those  Were  the  Happy  Days” 

“How  to  Prepare  a Talk” 

J.  H.  Henning 

Head,  Department  of  Speech,  West  \'irginia 
University  College  of  Arts  and  Sciences 

“Lantern  Slides  for  Lectures” 

Tom  Jones,  M.D. 

Professor  of  Medical  and  Dental  Illustrations, 
University  of  Illinois 


APRIL  4,  9:00  A.M. 

“What  to  Write  About  and  Where  to  Send  It” 
Morris  Fishbein,  M.D, 

Chicago,  Illinois 

“Illustrations  for  Manuscripts” 

Herman  Van  Cott 

Chief,  Illustrations  Division,  Armed  Forces  Insti-  ' 
tute  of  Pathology 


APRIL  4,  2:00  P.M. 

“Medical  Motion  Pictures” 

Warren  Sturgis 

President,  Sturgis-Grant  Productions, 

New  York  City 

“Building  a Personal  Library” 
Harold  Jeghers,  M.D. 

Professor  of  Medicine,  Georgetown  University 
School  of  Medicine 

“Showmanship  in  Teaching” 

Walter  F'reeman,  M.D. 

Professor  of  Neurology,  George  Washington 
University  School  of  Medicine 


154 


Conference  on  Medical  Teaching  Technics 


MARCH,  1952 


SATURDAY  MORNING,  APRIL  5,  9:00  A.M. 

PANEL  ON  INFORMAL  MEETINGS 
Wallace  M.  Yater,  M.D  , Moderator 
Director,  Yater  Clinic 

PARTICIPANTS 


Thomas  M.  Peery,  M.D. 

Director  of  Postgraduate  Instruction,  George 
ll’ashington  University  School  of  Medicine 


W.  Proctor  H.a.rvey,  M.D. 

Instructor  in  Medicine,  Georgetown  University 
School  of  Medicine 


Paul  Kiernan,  M.D. 

Associate  Professor  of  Surgery,  Georgetown 
University  School  of  Medicine 


E.  T.  Lisansky,  M.D. 

University  of  Maryland,  School  of  Medicine 


“Medical  Writing” 
Morris  Fishbein,  M.D. 
Chicago,  Illinois 


PANEL  ON  FORMAL  MEETINGS 

Brian  Blades,  M.D.,  Moderator 

Professor  of  Surgery,  George  Y'ashington  University 
School  of  Medicine 

PARTICIPANTS 

Walter  C.  Alvarez,  M.D.  J.  H.  Henning 

FAitor,  Modern  Medicine  Head,  Department  of  Speech,  West  Virginia  Uni- 

versity College  of  Arts  and  Sciences 


Julian  P.  Price,  M.D. 

Editor,  Journal  of  the  South  Carolina 
Medical  Association 


Hugh  H.  Hussey,  M.D. 

.\ssociate  Professor  of  Medicine, 
Georgetown  University  School  of  Medicine;  Editor,  GP 


REGISTER  NOW 

The  registration  fee  for  the  Conference  is  $10.00.  Physicians  who  desire  to  participate  should  register  not 
later  than  March  31.  Mail  your  check  to  Dr.  Hugh  H.  Hussey,  Chairman  of  the  Committee  on  iMedical 
Teaching  Technics,  1718  M Street,  N.W.,  Washington  6,  D.  C. 

NOTE  THE  RED  LETTER  DAYS,  APRIL  4 AND  5,  ON  YOUR  CALENDAR 


PSYCHIATRY  AND  RELIGION 


There  are  not  a few  signs  that  we  are  entering 
a new  day  in  the  relations  of  psychiatry  and  re- 
ligion. On  both  sides  of  what  seemed  for  a time 
a high,  barbed-wire  fence,  a new  respect  is  man- 
ifest for  what  takes  place  on  the  other  side  of  the 
barrier. 

In  this  connection  the  irenic  influence  of  the 
highly  popular  writings  of  the  late  Rabbi  Joshua 
Liebmann  may  be  cited.  The  keen  interest  of 
many  theological  seminaries  in  psychiatric  theory 
and  practice  and  their  prescription  of  clinical 
training  for  students  preparing  to  enter  the  min- 
istry has  not  been  without  a two-edged  effect. 
Many  psychologists  and  psychiatrists  have  found 
with  Dr.  Jung  of  Zurich  that  the  problems  of 
their  patients  are  in  the  last  resort  religious, 
paralleling  in  character  and  structure  those  which 
throughout  the  centuries  the  Church  has  diag- 
nosed and  attempted  to  solve. 

A concrete  example,  which  was  immensely 
stimulating  to  this  writer,  was  the  Ninth  Adelyn- 
rood  Conference  on  Theology  in  Action  held  at 
Newburyport,  Massachusetts,  last  Labor  Day 
week-end.  The  theme  was  “Faith,  Its  Theology 
and  Psychology.”  Those  participating  were 
principally  clergy,  lay  Church  workers,  social 
workers,  psychologists,  and  psychiatrists.  After 
four  papers  respectively  by  a theologian,  a re- 
search associate  in  psychiatry,  a psychiatry  pro- 
fessor from  a prominent  medical  school,  and  a 
pastoral  counselor,  all  dealing  with  faith  from 
some  angle,  there  was  a panel  discussion.  To  the 
embarrassment  of  the  theologian  (who  was  the 
writer  of  this  editorial),  almost  all  the  questions 
were  directed  at  him.  The  other  panelists  joined 
in  the  general  barrage.  What  was  striking  about 


the  questions  was  the  searching  and  sincere  con- 
cern generally  felt  about  the  “how”  of  faith.  How 
is  it  that  one  comes  to  believe? 

Undoubtedly  the  psychological  section  of  the 
Conference  in  question  was  exceptional.  Its  pres- 
ence at  that  particular  gathering  is  proof  of  this 
fact.  Yet  there  is  strong  reason  to  believe  that 
such  a phenomenon  expresses  a trend:  It  is  a 
straw  showing  the  direction  of  the  wind.  Like 
all  winds  this  one  is  from  beyond  conscious  in- 
dividual man.  It  is  mysterious  in  origination.  It  is 
“of  the  Spirit.”  We  can,  however,  as  individual 
clergy  and  psychiatrists  by  our  free  will  impart 
force  to  this  wind.  We  can  help  it,  by  our 
humility,  open-mindedness,  and  insight,  to 
become  a cleansing  gale.  If  this  happens,  both 
our  causes  which  have  so  much  in  common  will 
benefit. 

Psychiatry  is  a new  science.  (At  least  this  is 
true  as  a general  statement.  A Yale  anthropolo- 
gist has  recently  opined  that  the  oldest  profession 
is  not  that  of  the  proverbial  expression  but  is  the 
medicine  man,  and  that  the  medicine  man  was  a 
spiritual,  not  a physical  healer — in  short  a psy- 
chiatrist!) In  a brief  period  it  has  made  remark- 
able strides.  It  has  impressed  itself  profoundly 
upon  the  mentality  of  an  age.  It  has  influenced 
deeply  not  only  medicine,  but  art,  poetry,  the 
novel,  religion,  and  even  ethics  and  the  law.  It 
has,  however,  encountered  some  obstacles.  It  has 
found  that  the  territory  which  it  had  staked  out 
as  its  own  is  vast  and  that  the  soul  of  man  is  an 
obstinately  com[)licated  ])roposition.  Reacting 
with  appropriate  maturity  to  the  firm  realities 
that  cannot  be  conjured  out  of  existence,  psy- 
chiatry is  having  sober  second-thoughts.  It  is 


Opinions  expressed  in  contributions  to  the  Editorial  Section  are  those  oj  the  writers  and 
do  not  necessarily  reflect  the  views  oj  The  Medical  Society  oj  the  District  oj  C.olumhia. 

].S5 


156 


Editorials 


MARCH,  1952 


abandoning  the  cocksureness  and  dogmatism 
which  are  not  infrequently  the  accompaniment  of 
quick  success.  It  is  settling  down  with  becoming 
sobriety  to  the  long  pull. 

Religion,  by  contrast,  is  a very  old  performer, 
and  of  late  it  has  seemed  to  suffer  from  harden- 
ing of  the  arteries.  In  the  modern  period  it  has 
had  a good  many  hard  blows.  Some  of  these 
were  by  fate  or  circumstance.  Others  were  from 
inability  or  unwillingness  to  face  facts.  The  re- 
sultant necessity  of  abrupt  about-face  has  hurt 
the  credit  of  religion  and  turned  the  feet  of  many 
into  other  paths.  Yet  the  same  irreducible  con- 
ditions of  life  and  death,  love  and  hate,  remain. 
Primitive  man  and  modern  man  under  the 
surface  of  convention  and  social  habit  are 
astonishingly  alike.  The  challenge  of  ultimate 
frontiers  has  not  altered.  And  many  of  the  sub- 
stitutes for  faith  in  a meaningful  and  friendly  uni- 
verse have  failed,  leaving  man’s  last  estate  worse 
than  his  first.  Even  granting  that  religion  is  the 
result  of  a neurosis,  he  would  be  a bold  advocate 
who  would  contend  that  the  mental  and  spiritual 
state  of  man  in  the  twentieth  century  represents 
an  improvement  over  the  old  malady.  Be  this  as 
it  may,  religion  is  today  showing  signs  of  recover- 
ing its  second  wind.  It  is  finding  that  it  still 
meets  human  need.  It  is  discovering  anew  its  ap- 
peal to  high  and  low,  rich  and  poor,  intellectual 
and  simple.  As  it  does  so,  moving  in  with  a wide 
swing  of  time’s  never-resting  pendulum,  it  is  of 
paramount  moment  that  it  proceed  with  humil- 


* Lowry,  C.  W.:  Communism  and  Christ.  New  York; 
Morehouse-Gorham,  1952. 

FUNDS  NEEDED  FOR 

Present  statistics  indicate  that  1 out  of  every 
5 Americans  eventually  will  have  cancer.  For 
those  stricken,  the  chances  of  survival  are  now 
1 in  4.  This  figure  could  be  doubled  through  early 
diagnosis  and  prompt,  adequate  treatment. 

A recent  survey  made  for  the  American  Cancer 
Society  discloses  that  appro.ximately  30  million 
more  Americans  can  recognize  at  least  one  of  the 


ity,  vesting  itself  not  with  the  phylacteries  of 
senile  arrogance  but  with  the  white  raiment  of  a 
seasoned  and  unaging  maturity. 

Can  youth  and  age  thus  join  hands  and  work 
together?  Can  psychiatry  and  religion  pool  their 
strength  and  march  together  for  the  healing 
of  a world  that  is  deeply  disordered  and  des- 
perately sick?  I believe  that  they  can  and  will, 
for  they  are  bound  together  not  only  by  a com- 
mon mission  of  help  and  healing  but  by  common 
convictions  and  principles.  One  common  founda- 
tion, on  which  it  is  fitting  to  dwell  in  conclusion, 
is  the  primacy  of  love  in  the  ultimate  interpre- 
tation of  life. 

Sigmund  Freud,  the  father  of  modern  psy- 
chiatry, is  often  looked  on  by  leaders  of  thought 
in  all  fields  as  the  incarnation  of  irreligion  and 
the  sworn  underminer  of  ethics  and  morals.  From 
a superficial  glance  this  seems  to  be  true.  Upon  a 
longer  look,  however,  it  becomes  evident  that  in 
the  system  of  Freud  we  have,  in  the  fine  phrase 
of  Dr.  Karl  Stern,  “an  embryology  of  love.’’ 
From  the  standpoint  of  Christianity  building 
upon  the  twin-foundations  of  Judaism  and  Plato, 
this  is  a development  of  immense  significance. 
As  we  have  ventured  to  say  in  a recent  bookC 

“The  destiny  of  man,  it  seems,  positively  or  negatively, 
is  love.  He  cannot  escape  his  nature.  We  may  say  that 
Freud,  in  not  a few  ways  a second  .\ugustine,  is  one  of 
the  major  modern  prophets  preparing  the  way  for  the 
coming  in  new  splendor  and  power  of  Christ  the  Lord  of 
love.” 

Rev.  Charles  W.  Lowry,  Ph.1). 

Rector,  All  Saints'  Episcopal  Church, 
Chevy  Chase 

COMBATING  CANCER 

symptoms  of  early  cancer  today  than  were  able 
to  only  10  years  ago.  This  means  that  80  million 
people  are  now  aware  of  cancer’s  “seven  danger 
signals.” 

The  marked  increase  in  informed  people  can 
be  credited  largely  to  the  vigorous  and  compre- 
hensive public  education  program  of  the  Ameri- 
can Cancer  Society,  which  is  aimed  both  at  dis- 


VOL.  XXI,  NO.  3 


Medical  Annals  of  the  District  of  Columbia 


157 


semination  of  knowledge  of  symptoms  and  at 
fostering  a clear  understanding  of  the  nature  of 
cancer. 

Last  year  235,000  free  educational  booklets  on 
cancer  were  distributed  to  District  residents  and 
workers.  “Breast  Self-Examination,”  a motion 
picture  which  teaches  women  how  to  examine 
their  breasts  for  cancer  symptoms,  has  been 
shown  to  more  than  28,000  women  in  Washington. 

This  educational  effort  is  combined  with  the 
Society’s  research  and  service  programs.  Nation- 
ally the  ACS  has  awarded  1 ,200  grants  to  scien- 
tists since  1945  to  investigate  the  cause  of  cancer. 
Last  year  $27,000  was  granted  to  institutions  and 
individuals  in  the  District  of  Columbia. 

The  service  program  of  the  local  Society  last 
year  supplied  Washington  cancer  patients  with 
more  than  100,000  surgical  dressings;  it  financed 
2,300  home  nursing  visits  to  needy  cancer  vic- 
tims; $5,200  was  allocated  to  help  care  for  can- 
cer sufferers  at  the  Washington  Home  for  In- 


curables; $48,000  was  granted  for  the  support  of 
five  local  tumor  clinics. 

Until  a cure  for  cancer — long  hoped  for  and 
patiently  sought-  has  been  discovered,  educa- 
tion, research  and  service  represent  the  only 
weapons  of  control.  These  activities  make  up  the 
three-pronged  attack  by  which  the  American 
Cancer  Society  is  combating  the  menace  of  cancer. 

This  life-saving  work  must  continue.  Whether 
it  does  or  not  depends  on  our  determination,  our 
courage  and  our  generosity.  The  American  Can- 
cer Society  will  conduct  its  annual  fund-raising 
drive  in  April.  A sum  of  $225,000  is  needed  this 
year  to  finance  programs  of  education,  research 
and  service  in  Washington.  Your  contribution  to 
the  Cancer  Crusade  will  be  appreciated.  Send 
your  donation  to  the  American  Cancer  Society, 
1415  Eye  Street,  N.W.,  Washington  5,  D.  C. 
Murray  M.  Copeland,  M.D. 
President,  District  of  Columbia 
Division,  American  Cancer  Society 


THE  COMPLAINTS  THAT  REACH  OUR  GRIEVANCE  COMMITTEE 


The  past  two  decades  have  brought  forth  an 
unprecedented  public  criticism  of  the  personal  re- 
lationship of  doctors  to  their  patients.  At  first 
the  profession  tended  to  shrug  off  or  minimize 
this  unpleasant  phenomenon,  but  today  it  has 
become  everywhere  the  subject  of  earnest  med- 
ical attention  and  planned  action. 

.\mong  the  pioneer  remedial  ventures  over  the 
Nation  was  the  establishment  by  our  Medical 
Society,  in  1939,  of  a Grievance  Committee, 
charged  with  receiving  and  adjudicating  specific 
complaints  against  individual  physicians  and  also 
complaints  by  one  physician  against  another. 
This  Committee  has  become  one  of  the  busiest 
and  most  important  within  the  Society,  and  its 
work  is  one  of  our  most  realistic  and  effective 
answers  toward  improved  public  relations  and 
the  reduction  of  law  suits  against  doctors. 

During  the  past  year  the  Committee  has  re- 
ceived an  average  of  12  complaints  a month.  It 


takes  little  imagination  to  visualize  the  amount 
of  work  involved  in  investigating  such  a volume 
of  grievances.  Yet  all  who  have  helped  shoulder 
this  burden  as  members  of  the  Committee  have 
been  deeply  impressed  by  the  need  for  what  is 
being  done.  Also,  the  experience  of  service  on 
the  Grievance  Committee  may  be  described  as 
exceedingly  valuable  postgraduate  medical  edu- 
cation. 

The  general  types  of  complaint  brought  before 
the  Committee  may  be  classified  as  follows  (ar- 
ranged in  approximate  order  of  fref|uency) : 

1 . Excessive  charge  for  services. 

2.  Complaint  about  charges  which  the  pa- 
tient did  not  contemplate  under  an  original  dis- 
cussion of  costs. 

3.  Complaint  by  a Medical  Service  subscriber 
that  the  doctor  has  added  an  unjustified  charge 
above  Medical  Service  coverage. 

4.  Incompetent  and/or  negligent  treatment. 


158 


Editorials 


MARCH,  1952 


5.  Failure  of  the  doctor  to  respond  to  emer- 
gency or  night  calls. 

6.  Discourteous  treatment  at  the  hands  of 
members  of  the  doctor’s  office  staff  or  family. 

7.  Discourteous  or  threatening  treatment  in- 
cident to  the  collection  of  bills. 

8.  Failure  to  call  consultants  or,  on  the  con- 
trary, excessive  use  of  consultants  and/or  labo- 
ratory procedures. 

9.  Allegation  that  the  doctor  experimented 
with  untried  methods  or,  on  the  other  hand,  that 
he  failed  to  use  modern  methods. 

10.  Complaint  that  certain  therapeutic  re- 
sults were  guaranteed  and  failed  to  materialize. 

1 1 . Alleged  demands  for  prepayment  for  serv- 
ices in  an  emergency  or  on  a night  call. 

12.  Alleged  failure  of  the  doctor  to  be  helpful 
in  guiding  the  patient  to  another  physician  when 
unable  or  unwilling  to  take  the  case  himself. 

13.  Allegation  that  the  doctor  made  a fright- 
ening diagnosis  or  prognosis  without  foundation. 

14.  Complaint  by  one  physician  against 
another,  usually  related  to  alleged  lack  of  pro- 
fessional courtesy  in  mutual  relations  with  a pa- 
tient. 

Iffirough  service  on  the  Crievance  Committee 
one  gains  the  impression  that  many  of  the  com- 
plaints received  have  a certain  basis  in  fact, 
usually  attended  by  much  misunderstanding 
which  could  have  been  avoided  had  the  doctor 
exercised  a bit  more  time,  patience  and  personal 
interest.  Some  complainants  are  clearly  irrational 
and  have  small  foundation  for  their  grievances, 
yet  even  in  these  cases  it  often  seems  that  the 
doctor  might  have  avoided  the  complaint  by 


recognizing  the  patient’s  personality  charac- 
teristics and  displaying  exceptional  forbearance 
and  tact  instead  of  standing  rather  stiffly  upon 
his  sense  of  justice.  It  may  safely  be  assumed 
that  most  doctors  do  display  exceptional  tact 
with  severely  neurotic  persons  or  the  work  of  the 
Committee  would  be  many  times  the  present 
volume. 

It  is  often  an  obvious  shock  to  a conscientious 
doctor  to  be  required  to  answer  a complaint  to 
the  Grievance  Committee,  but  most  do  so  in  a 
good  spirit  and  with  full  cooperation.  On  that 
basis  most  cases  are  compromised  or  settled 
amicably,  but  in  rare  instances  cooperation  is 
poor.  When  this  is  so,  or  when  the  complaint  is 
believed  to  be  justified,  the  Committee  does  not 
hesitate  to  take  appropriate  disciplinary  action. 
Since  doctors  are  subject  to  all  human  frailties, 
it  is  inevitable  that  the  Grievance  Committee 
should  find  among  them  an  occasional  badly  ad- 
justed and  irresponsible  personality  from  whom 
the  public  and  our  own  professional  repute  must 
be  protected. 

It  is  suggested  that  most  of  the  complaints  to 
which  the  Grievance  Committee  listens,  includ- 
ing those  involving  money,  arise  from  lack  of  a 
sufficiently  warm  and  personal  kind  of  relation- 
ship between  doctor  and  patient.  Even  though 
achievement  of  that  often  takes  more  time  than 
seems  available,  it  is  an  effort  that  should  never 
be  dismissed  lightly,  since  people  who  like  us 
personally  don’t  sue  us  or  complain  about  us  to 
the  Grievance  Committee. 

W.XLTER  Stokes,  M.D. 

Chairman,  Grievance  Committee 


NEW  AND  NEWSWORTHY  MEDICAL  JOURNALS 


Along  with  head  colds  and  virus  infections, 
January  brought  out  a rash  of  new  medical 
journals.  Several  of  them  are  of  such  high  calibre 
as  to  deserve  more  than  casual  mention  in  our 
news  columns.  We  hope  our  readers  will  not 
desert  the  Annals  for  greener  fields,  but  we 


warmly  recommend  the  newcomers  for  supple- 
mentary reading. 

A new  specialty  journal.  Diabetes,  has  consider- 
able local  interest.  On  its  Editorial  Board  of 
seventeen  distinguished  physicians  are  two  mem- 
bers of  the  Medical  Society  of  the  District  of 


VOL.  XXI,  NO.  3 


Medical  Annals  of  the  District  of  Columbia 


159 


Columbia,  our  Editor,  Dr.  Wallace  M.  Yater, 
and  Dr.  Russell  M.  Wilder,  Associate  member, 
who  recently  retired  from  the  Mayo  Foundation 
and  is  Director  of  the  National  Institute  of 
Arthritis  and  Metabolic  Diseases  of  PHS.  Dia- 
betes is  the  official  organ  of  the  American  Dia- 
betes Association,  whose  Secretary  is  Dr.  John 
A.  Reed,  an  Active  member  of  the  District  Med- 
ical Society  and  national  Chairman  of  the  1952 
Diabetes  Detection  Drive.  The  Executive  Di- 
rector of  ADA,  and  to  whom  much  credit  is  due 
for  the  inauguration  of  this  bimonthly  journal,  is 
J.  Richard  Connelly,  who  served  as  Assistant 
Secretary  of  our  Society  for  three  years. 

The  January-February  number  of  Diabetes 
comes  to  us  with  a drawing  on  its  cover  of  the 
late  Sir  Frederick  G.  Banting,  co-discoverer  with 
Dr.  Charles  H.  Best,  of  the  University  of  To- 
ronto, of  insulin  and  its  use  in  the  control  of  dia- 
betes. The  editor  is  Dr.  Frank  N.  Allan,  of  the 
Fahey  Clinic,  who  will  be  advised  by  the  Edi- 
torial Board  under  the  chairmanship  of  Dr.  Best. 
The  issue  opens  with  a “Salute  to  Diabetes”  by 
Dr.  Elliott  P.  Joslin,  of  Boston,  Honorary  Presi- 
dent of  ADA.  The  leading  scientific  paper  is  the 
Banting  Lecture  for  1951  by  Dr.  C.  N.  H.  Long 
of  Yale  University.  Large  sections  are  devoted 
to  proceedings  of  the  ADA  and  to  abstracts  of 
articles  in  the  field  of  diabetes,  since  the  new 
journal  is  a combination  of  two  previous  pub- 
lications, Proceedings,  which  appeared  annually, 
and  Diabetes  Abstracts,  a cjuarterly. 

Our  sister  component  society  to  the  north,  the 
Medical  and  Chirurgical  Faculty  of  the  State  of 
Maryland,  has  issued  the  first  number  of  the 
Maryland  State  Medical  Journal,  a publication 
which  gives  promise  of  upholding  the  dignity  of 
this  venerable  organization. 

In  his  Foreword,  Dr.  George  H.  Yeager,  Secre- 
tary of  the  Faculty  and  Editor  of  the  Journal, 
points  out  that  the  Journal  is  not  a new  venture 
but  the  reestablishment  of  a former  publication. 
Previous  publications  of  the  Faculty  were  the 
Maryland  Medical  and  Surgical  Journal  and 
Official  Organ  of  the  Medical  Department  of  the 


Army  and  Navy  of  the  United  States  (1839  to 
1843)  and  a monthly  Bulletin,  published  from 
1908  to  1922.  During  the  years  1887  to  1918  the 
Maryland  Medical  Journal  carried  notes  and 
communications  of  the  Faculty  and  for  a brief 
period,  1905-8,  was  the  official  publication  me- 
dium of  the  Faculty.  The  Journal  replaces  a 
small  Bulletin  which  has  been  issued  by  the 
Faculty  since  1927. 

In  its  bottle-green  dress,  Ptddic  Health  Reports, 
larger  than  its  predecessor,  bears  no  resemblance 
except  in  name  to  the  GPO  publication  it  re- 
places. Although  the  January  issue  is  Number  1 
of  Volume  67,  the  monthly  Reports  is  almost 
“new,”  since  it  is  an  amalgamation  of  the  former 
weekly  Public  Health  Reports  with  the  monthly 
Tuberculosis  Control  Issue  of  Public  Health  Re- 
ports, the  monthly  Journal  of  Venereal  Disease 
Information,  and  the  monthly  CDC  Bulletin. 

Mr.  Howard  Ennes  is  Executive  Editor  and 
Mr.  Taft  S.  Feiman,  Managing  Editor,  of  PHR. 
Dr.  Edward  G.  McGavran,  Dean  of  the  Uni- 
versity of  North  Carolina  School  of  Public 
Health,  is  Chairman  of  a distinguished  Board  of 
Editors,  which  includes  authorities  not  only  in 
the  field  of  medicine  but  in  allied  professions. 
Among  them  is  Dr.  Wilder,  previously  mentioned 
in  this  article.  Surgeon  General  Scheele  has  writ- 
ten the  introductory  statement  for  the  January 
issue. 

PHR  is  an  attractive  and  readable  journal,  a 
credit  to  the  Public  Health  Service,  a branch  of 
the  Federal  Security  Agency.  Its  120  pages  are 
packed  with  scientific  information.  This  first  issue 
contains  13  signed  articles,  with  subject  matter 
ranging  from  Trichophyton  tonsurans  ringworm 
to  salaries  of  state  health  department  {)ersonnel. 
Its  table  of  contents  indicates  the  vast  scope  of 
activities  of  the  Public  Health  Service,  which 
has  a corresponding  reservoir  of  contributors. 
Physicians  who  like  historical  data  will  enjoy 
the  first  article,  which  traces  the  history  of  Ptib- 
lic  Health  Reports  from  its  one-page  beginning  as 
a Bidletin  in  1878  to  its  present  expanded  form. 

The  advent  of  the  Journal  of  the  Student  Amer- 


160 


Editorials 


ML4RCH,  1952 


icon  Medical  Association  was  reported  briefly  in 
the  news  columns  for  I'ebruary,  but  the  Journal 
assuredly  deserves  mention  here  along  with  other 
new  scientific  journals. 

The  Journal  of  the  Student  AM  A is  most  con- 
sjiicuous  for  its  ambitious  beginning.  Like  the 
usual  golden,  fluffy  chick,  it  bears  little  resem- 
blance to  J .A  .M.A.,  the  mature  parent  bird.  The 
enviable  exuberance  of  youth  is  reflected  in  its 
use  of  color,  elaborate  lay-out,  and  profuse  illus- 
trations. It  is  not  too  surprising  to  learn  from 
Russell  F.  Staudacher,  Executive  Editor,  that 
the  Chicago  artist  for  Life  and  Look  was  called 
upon  to  design  this  most  attractive  mouthpiece 
of  an  organization  which  was  only  one  year  old 
on  December  29,  1951.  The  Student  Journal 
should  not  have  so  much  difficulty  striving  for 
greater  goals  as  for  maintaining  the  high  standard 
it  has  already  set  for  itself. 

A large  section  of  the  first  issue  is  devoted  to 
socioeconomic  articles,  none  of  them  of  a con- 
troversial nature.  The  leading  scientific  article  is 
one  on  “Surgery  and  Bronchiectasis”  by  Dr. 
Robert  M.  Janes,  of  the  University  of  Toronto. 
The  other  two  are  by  medical  students,  Herbert 
A.  Saltzman,  of  Jefferson  Medical  College,  and 
Raymond  W.  Browning,  of  Tulane  University. 
Not  of  least  interest  to  this  reader  was  Local  An- 
esthesia, a series  of  drawings  by  Bruce  W.  Pine 
reminiscent  of  the  Xev.  Yorker's  sophisticated 
brand  of  humor. 

'I'he  Journal  of  the  Student  AM  A will  be  pub- 
lished nine  times  a year.  It  is  distributed  without 
charge  to  American  medical  students  and  in- 
terns. The  modest  subscription  rate  of  $5.50  per 
year  will  appeal  to  physicians  who  still  maintain 
an  interest  in  medical-student  activities. 

Praiseworthy  too  is  the  Journal  of  the  Medical 
Association  of  Georgia,  which  begins  its  41st  year 
of  publication  with  a bright  and  cheerful  counte- 
nance. Its  new  dress  is  not  confined  to  the  cover; 
the  entire  journal  has  been  revamped.  The  “new 
look”  has  been  accomplished  primarily  by  dis- 
tinctive article  headings  and  well  illustrates  what 
can  be  done  economically  by  means  of  typog- 
raphy alone.  Dr.  David  Henry  Poer  and  his 


assistants  can  be  proud  of  the  face-lifting  which 
characterizes  their  self-styled  “Miss  1952.”  It  ap- 
pears too  that  the  Editorial  Board  has  given  its 
readers  a well  balanced  diet. 

Readers  who  have  stayed  with  me  thus  far  may 
be  interested  in  some  comments  apropos  the  be- 
ginnings of  our  own  medical  journal.  The  date  of 
origin  of  state  medical  journals  was  brought  up 
at  the  recent  State  Editors’  Conference  in 
Chicago,  but  few  of  the  editors  knew  how  long 
their  journals  had  been  in  existence,  since  many 
of  them,  like  our  owm,  had  had  precarious  be- 
ginnings and  had  not  been  published  contin- 
uously from  the  date  of  their  inception. 

An  article  by  Dr.  John  B.  Nichols,  published 
in  the  first  issue  (January  1952)  of  Volume  1 of 
the  Medical  Annals  gives  a brief  history  of 
the  publications  of  the  District  Medical  Society. 
Erom  1871  on,  a number  of  local  medical  journals 
came  into  existence,  only  to  e.xpire  after  a few 
volumes  had  been  published.  Proceedings  of  the 
Society  were  thus  bandied  about  among  a num- 
ber of  short-lived  publications.  In  spite  of  this. 
Dr.  Nichols  observed,  the  proceedings  of  the 
Society  were  published  “in  adequate  and  credit- 
able form”  from  1892  to  1917.  During  that  time 
the  most  flourishing  publication  was  the  IFas//- 
ington  Medical  Annals,  a bimonthly  journal 
under  the  editorial  management  of  Dr.  Daniel  S. 
Lamb,  which  continued  for  19  volumes,  from 
1901  to  1920.  In  1924,  Dr.  Coursen  B.  Conklin, 
then  Secretary  of  the  Society,  started  a monthly 
Bulletin,  which  was  succeeded  in  January  1952 
by  the  Medical  Annals  of  the  District  of 
Columbia.  Dr.  Wallace  M.  Vater,  the  first  Ed- 
itor of  the  Annals,  began  his  21st  year  as  editor 
of  the  Society’s  publication  in  January  of  this 
year.  Dr.  Conklin  was  the  first  Managing  Editor 
and  was  succeeded  in  that  post  by  Theodore 
Wiprud,  the  first  lay  Secretary  of  the  Society,  in 
1958. 

In  the  early  days  of  publication  the  Editorial 
Committees,  as  reported  in  Dr.  Lamb’s  History 
of  the  Society,  had  much  difficulty  keeping  within 
the  publication  budgets.  This  is  understandable 
when  we  note  that  the  budget  for  1902,  for  in- 


VOL.  XXI,  NO.  3 


Medical  Annals  of  the  District  of  Columbia 


161 


stance,  was  $600.  For  the  year  1907  the  History 
records  that  the  Annals  showed  a net  cost  of 
$1.13  per  page,  which  “covered  all  expenses  in- 
cident to  the  publication.’’  Today  this  is  the 


approximate  cost  of  the  paper  for  one  page. 
For  doctors,  publishing,  it  seems,  has  always  been 
an  expensive  activity. 

A.  L.  E. 


Jt0.t 


BY  THE  OBSERVER 


It  would  be  interesting  to 
know  how  many  members  of  our 
Medical  Society  have  read  its 
Constitution  and  By-laws,  in 
whole  or  in  part.  Probably  very  few,  because 
admittedly  it  is  unexciting  reading.  To  the  his- 
torically-minded, however,  it  is  most  rewarding. 

Members  who  were  active  in  the  Society  im- 
mediately prior  to  the  adoption  of  the  present 
Constitution  and  By-laws  in  January,  1939  and 
who  had  an  up-to-date  copy  in  their  possession 
will  remember  how  cluttered  it  was  with  amend- 
ments, deletions  and  corrections.  In  fact,  the  in- 
serts which  had  been  pasted  in  as  nearly  as 
possible  to  the  texts  to  which  they  related  were 
so  numerous  that  some  parts  of  the  document 
were  obscure. 

One  had  only  to  read  the  amendments  to  be- 
come aware  of  the  trials  and  tribulations  which 
had  engulfed  the  Society  during  the  mid-thir- 
ties. Certainly  they  were  an  indication  of  the  in- 
stability of  that  period. 

In  the  years  which  followed,  the  Society  en- 
tered quieter  waters.  Amendments  and  other 
changes  in  the  Constitution  and  By-laws,  while 
quite  numerous,  have  not  been  of  too  vital  a 
nature.  They  include  the  reduction  in  number  of 
business  meetings,  the  creation  of  new  member- 
ship classifications,  i.e..  Affiliate  and  Resident- 
Intern  memberships,  a modest  upping  of  the 
dues  in  the  various  membership  categories,  and 
a revision  of  the  procedure  in  electing  appli- 
cants to  membership.  While  these  modifications 
have  not  vitally  altered  the  Society’s  structure 


Organization 

Structure 

Studied 


or  the  manner  in  which  it  conducts  its  operations, 
changes  wrought  by  time  and  circumstances,  it 
now  appears,  will  have  a profound  effect  upon 
the  organization  and  its  future. 

The  1940’s  were  a period  of  swift  movement. 
The  face  of  society  was  altered  more  radically 
than  in  the  previous  25  years.  In  the  light  of 
these  developments  the  Executive  Board  has  de- 
cided to  reappraise  the  Society’s  Constitution 
and  By-laws.  It  might  be  mentioned  in  passing 
that  this  action  was  taken  largely  at  the  behest 
of  Dr.  Frank  D.  Constenbader,  President  of  the 
Society,  who  has  felt  that  there  are  contradic- 
tions in  the  Constitution  and  By-laws  which 
should  receive  early  attention,  and  that  the  need 
for  revision  of  many  of  its  provisions  should 
also  be  given  consideration. 

Among  Dr.  Costenbader’s  proposals  is  one 
which  would  change  the  organization  year  from 
a fiscal  to  a calendar  basis.  If  the  suggestion  is 
approved,  officers  of  the  Society  will  take  office 
on  January  1 instead  of  July  1.  Arguments  ad- 
vanced by  Dr.  Costenbader  in  favor  of  this 
change  are  that  the  Society’s  financial  records 
are  kept  on  a calendar  basis  and  that  the 
Society’s  program  is  so  arranged  that  its  climax 
comes  in  the  late  fall  when  the  Annual  Scien- 
tific Assembly  is  held.  At  the  present  time,  the 
President  takes  office  three  months  prior  to  the 
Society’s  most  ambitious  undertaking,  the  re- 
mainder of  the  year  lieing  an  anticlimax.  Dr. 
Costenbader’s  feeling  is  that  the  .\ssembly 
should  be  the  high  point  in  the  President’s  term 
of  office. 


162 


In  and  Out  of  Focus — Observer 


^LA.RCH,  1952 


Another  argument  in  favor  of  this  change  is 
that  the  Society’s  delegates  to  the  American 
Medical  Association  serve  on  a calendar  basis  al- 
though they  are  elected  by  the  Society  for  a two- 
year  term  beginning  on  July  1.  As  a result  they 
carry  on  for  six  months  after  the  election  of  their 
successors. 

There  has  been  discussion,  too,  of  shortening 
the  terms  of  officers  of  the  Society.  Some  have 
expressed  the  view  that  the  terms  of  some  are 
too  long  and  that  they  might  be  shortened  with- 
out jeopardizing  the  continuity  of  the  Society’s 
program. 

These  and  other  suggestions  will  be  brought  to 
the  attention  of  the  recently  appointed  Com- 
mittee on  Revision  of  the  Constitution  and  By- 
laws. Because  of  its  nature,  the  Committee’s 
task  will  require  several  months,  and  it  will  do 
well  if  it  is  prepared  to  report  by  the  end  of  the 
year. 

Members  of  the  Committee  are:  Dr.  Walter 
Freeman,  Chairman,  Dr.  William  M.  Ballinger, 
Dr.  Frank  D.  Costenbader,  and  Dr.  Harry 
Zehner. 

★ 


The  Ruffin 
Bequest 


All  of  us  can  recall  incidents 
which  though  trivial  in  them- 
selves have  left  an  indelible  im- 
pression on  our  memories.  An  example  of  this  is 
an  incident  which  occurred  when  your  Observer 
first  came  to  Washington  in  the  late  1930’s. 
The  District  Medical  Society  was  then  passing 
though  a tumultuous  period  and  valiant  efforts 
were  being  made  by  its  leaders  to  stabilize  the 
organization.  Means  finally  adopted  to  achieve 
this  end  were  simplicity  itself.  First  of  all,  agenda 
for  business  meetings  of  the  Society  were  planned 
with  the  determination  that  they  would  be  ad- 
hered to.  Thoughtfully  prepared  reports  sup- 
planted free-for-all  discussions,  which  more  often 
than  not  led  to  bitter,  inconclusive  sessions.  It 
was  a new  experience  for  the  Society,  but  mem- 
bers fortunately  were  willing  to  give  the  new 
endeavor  a try. 

Your  Observer  recalls  the  tenseness  of  the 


Society’s  officers  when  the  new  order  made  its 
bow.  The  first  meeting  was  successfully  hurdled. 
At  the  close  of  the  second,  a dignified,  white- 
haired  doctor  with  a courtly  manner  said  to 
your  Observer,  “Young  man,  this  is  the  best  con- 
ducted meeting  I recall  since  I have  been  a 
member  of  the  Society.”  Pleased,  your  Observer 
inquired  of  an  officer  the  doctor’s  name.  He  was 
told  that  it  was  Dr.  Sterling  Ruffin.  While,  of 
course,  your  Observer  had  not  conducted  the 
meeting  he  had  had  a hand  in  implementing  it 
and  the  compliment  was  most  welcome.  The  re- 
mark stuck  in  his  mind  and  fourteen  years  later 
he  is  still  grateful  for  the  timely  lift. 

Subsequently  your  Observer  came  to  know  a 
great  deal  more  about  this  distinguished  Wash- 
ington physician.  He  learned  that  he  was  es- 
teemed not  only  as  a doctor  but  as  an  educator. 
He  discovered,  too,  that  Dr.  Ruffin  was  a prom- 
inent civic  leader  and  highly  regarded  in  finan- 
cial circles;  that  many  honors  had  come  to  him 
in  a long  and  useful  life. 

Shortly  after  his  retirement  Dr.  Ruffin  called 
your  Observer  to  his  Connecticut  Avenue  apart- 
ment and  informed  him  of  his  plan  to  leave  a 
portion  of  his  estate  to  the  Medical  Society  for 
needy  members.  At  his  recjuest  nothing  was  said 
of  his  decision  at  the  time.  Subsequent  to  his 
death  the  Society  was  notified  that  Dr.  Ruffin’s 
will  contained  the  following  bequest: 

“.  . . I give,  devise,  and  bequeath  as  follows,  to-wit: 

“K.  Three-fortieths  (3/40)  thereof  to  the  Medical 
Society  of  the  District  of  Columbia  to  be  used  for  the 
relief  of  ill  or  superannuated  needy  active  or  life  members 
of  that  Society. 

“.\wards  from  this  fund  shall  be  made  in  cash  in  the 
discretion  of  a majority  of  a special  committee  of  five 
(5)  members  appointed  by  the  President  of  the  Society. 
No  member  of  such  Committee  shall  serve  for  a longer 
period  than  two  (2)  years.  Reports  of  e.xpenditures  shall 
be  made  from  time  to  time  by  the  Committee  to  the 
Society,  without,  however,  disclosing  the  names  of  the 
beneficiaries.” 

In  compliance  with  the  above  provisions.  Pres- 
ident Frank  D.  Costenbader  has  appointed  the 
following  Committee  on  the  Ruffin  Bequest:  Dr. 


Medical  Annals  of  the  District  of  Columbia 


163 


VOL.  XXI,  NO.  3 

Daniel  L.  Borden,  Chairman,  Drs.  Henry  C. 
Macatee,  R.  Massie  Page,  Richard  E.  deButts, 
and  James  J.  McFarland,  Jr. 

Cash  and  securities  in  the  amount  of 
$18,001.56  have  been  turned  over  to  the  So- 
ciety’s Treasurer  by  the  Riggs  National  Bank. 
These  are  now  at  the  disposal  of  the  Committee, 
which  has  asked  that  the  Society’s  membership 
be  notified  of  the  bequest  and  that  it  is  prepared 
to  give  assistance  in  accordance  with  the  terms 
of  Dr.  Ruffin’s  will. 


Behind 
the  Scenes 


Typical  of  the  activity  in  the 
Medical  Society’s  Executive 
Offices  preceding  an  important 
event  were  the  preparations  for  the  recent  Mid- 
winter Seminar.  Two  meetings  of  the  Progam 
Committee  were  held  well  in  advance  of  the 
Seminar,  notes  being  taken  on  the  proceedings. 
These  were  dictated  and  transcribed  immedi- 
ately afterward  for  the  guidance  and  information 
of  the  Committee  and  the  office  staff.  As  days 
passed  there  was  an  increasing  number  of  tele- 
phone calls  from  and  to  the  Chairman  of  the 
Committee  and  others  connected  with  the  meet- 
ing. Tentative  drafts  of  the  program  were  eventu- 
ally turned  over  to  the  office  staff  for  typing.  xA.s 
is  always  the  case  there  were  a number  of  changes 
before  the  program  was  finally  approved. 

Upon  your  Observer’s  request  the  Chairman 
wrote  an  editorial  for  the  Medical  Annals  and 
this  together  with  the  program  was  turned  over 
to  the  Assistant  Editor  for  publication.  The 
printers  were  then  called  in  and  the  lay-out  and 
type  to  be  used  in  a folder  publicizing  the  Sem- 
inar were  decided  upon.  Three  thousand  folders 
were  ordered.  The  text  of  the  postcard  announce- 
ments was  prepared  and  a sufficient  number 
ordered  for  mailing  to  all  members  of  the  So- 
ciety. Placards  were  also  ordered  to  be  posted 
in  various  medical  centers,  hospitals  and  other 
medical  institutions.  These  were  distributed  {)er- 
sonally  by  an  employee  of  the  Society. 

Letters  were  sent  to  chiefs  of  the  Army,  Navy 
and  Public  Health  Service  in  which  an  invitation 


was  extended  to  their  medical  personnel  to  at- 
tend the  Seminar.  Finally  there  were  last-minute 
details  to  be  attended  to,  such  as  the  employ- 
ment of  an  operator  to  project  slides  and  motion 
pictures,  testing  of  amplifying  equipment,  and 
seeing  to  it  that  various  items  needed  by  speakers 
were  on  hand. 

Mr.  Lawrence  A.  Zupan,  Executive  Assistant, 
and  your  Observer  were  discussing  the  immense 
amount  of  detail  work  which  falls  to  the  clerical 
staff  when  it  occurred  to  them  that  a month’s 
work  schedule  might  be  enlightening  to  readers 
of  this  column.  Your  Observer  asked  Mr.  Zupan 
to  compile  a list  of  the  office  procedures  and 
details  handled  by  the  staff  in  January.  The  re- 
sult follows; 

Billing  1,687  members  for  1952  Medical  Society  dues. 
Inserting  1,777  names  on  membership  cards. 

Preparing  the  annual  membership  report. 

Stenciling  and  mimeographing  roster  of  1,777  members 
(approximately  50  copies  of  57  pages  each). 

Billing  1,090  members  for  1952  AM  A dues. 

Billing  735  Medical  Bureau  subscribers. 

Checking  2,300  addressograph  plates  for  current  ad- 
dresses. 

Closing  books  for  annual  audit  and  preparation  of  annual 
financial  reports. 

Consolidation  of  Medical  Society,  Medical  Bureau  and 
Medical  Annals  funds  of  the  Society  as  instructed 
by  the  Executive  Board  and  establishing  a new  dues 
record  system. 

Preparing  letter,  ballot  and  return  envelope  for  Nominat- 
ing Committee  (mailed  to  1,375  voting  members). 
Preparing  letter  and  return  envelope  for  canvass  of  mem- 
bers to  determine  interest  in  group  accident  and  health 
insurance  (mailed  to  1,303  members). 

Working  out  program  details  and  distributing  1,850 
Midwinter  Seminar  programs  (see  above). 

Mailing  1,850  postcard  notices  in  advance  of  Midwinter 
Seminar. 

Compiling  and  mailing  four-page  Calendar  of  Meetings 
(1,850  copies). 

.Addressing  1,777  envelopes  for  mailing  membershij)  cards. 
Stenographic  and  clerical  duties  incidental  to  actions  of 
Executive  Board  and  various  committees. 

■Addressing  2,300  envelopes  for  mailing  of  Medical 
■Annals. 

Canvassing  1,777  members  to  determine  how  many 
wished  to  be  placed  on  a list  of  physicians  who  would 
immunize  those  who  plan  to  travel  al)road. 


164 


In  and  Out  of  Focus — Observer 


M,4RCH,  1952 


Mimeographing  letters  and  postcards  urging  cooperation 
of  members  in  nursing  resources  survey  (1,777  copies 
of  each). 

Mailing  of  60  letters  to  members  inviting  them  to  Mem- 
bership Luncheons. 

Preparing  and  mailing  of  notices  of  Section  and  Woman’s 
.\uxiliary  meetings. 

■Arranging  tletails  for  dinners  and  luncheons  of  Executive 
Board  and  committees  (3  dinners  and  1 luncheon). 

Billing  of  1 ,000  member-subscribers  of  Group  Hospitali- 
zation, Inc. 

General  correspondence. 


The  above  list  is  published  with  full  apprecia- 
tion that  the  ofhee  staff  are  paid  for  their  serv- 
ices. Ordinarily,  there  would  be  no  reason  to 
comment  one  way  or  another.  How'ever,  the 
present  staff  deserves  recognition  for  their  un- 
usual diligence  and  loyalty. 

No  “made”  paper  work  is  being  done  in  the 
Society’s  Executive  Offices.  Every  assignment  is 
scrutinized  to  be  certain  it  is  necessary.  Members 
can  therefore  be  certain  that  little  time  is  wasted ; 
furthermore,  that  the  mail  they  receive  from  the 
Medical  Society  has  been  appraised  from  the 
standpoint  of  its  essentiality  and  is  therefore 
deserving  of  their  careful  attention. 

Your  Observer  is  pleased  to  acknowledge  the 
competent  work  of  “his”  staff.  They,  after  all, 
make  the  wheels  go  around. 

★ 


An  estimated  ninety  per  cent 
^ complaints  lodged  with 

the^I^ublic  Medical  Society’s  Grievance 
Committee  by  irate  patients 
have  to  do  with  fees.  While  in  most  instances 
the  facts  do  not  justify  the  charge  that  the  doc- 
tors have  taken  unfair  advantage  of  them,  they 
do  point  to  the  need  for  corrective  measures. 
It  is  your  Observer’s  opinion  that  most  of  these 
comj)laints  could  have  been  avoided  if  there  had 
been  frank  and  friendly  discussion  between  the 
physician  and  patient.  Under  such  circumstances 
there  would  be  little  chance  for  misunderstanding 
and  the  recriminations  which  so  often  ensue. 

Unfortunately  for  everyone  concerned,  efforts 
to  remedy  this  situation  have  to  date  not  been 


too  effective.  Both  sides  are  too  often  unrea- 
sonable and  pride  will  not  permit  them  to  compro- 
mise. Articles  have  appeared  at  infrequent  in- 
tervals in  medical  journals  urging  physicians  to 
make  an  effort  to  avoid  needless  disagreements. 
The  Grievance  Committee  has  also  performed  a 
valuable  service*  in  an  effort  to  eliminate  ob- 
viously unnecessary  complaints.  However,  much 
more  needs  to  be  done.  Perhaps  a minimum  fee 
schedule  for  the  guidance  of  physicians  in  private 
practice  and  for  the  information  of  their  patients 
would  be  helpful. 

As  late  as  1939  such  a fee  schedule  was  in 
effect  in  Washington.  Officials  of  the  Medical 
Society  considered  it  ineffective  and  of  little 
value  because  the  minimum  fee  for  each  pro- 
cedure listed  was  followed  by  the  words  “and 
up.”  It  seemed  to  them  that  such  a schedule  did 
little  more  than  keep  a floor  under  a doctor’s 
charges.  Evidently  many  other  physicians  were 
of  a like  mind  for  shortly  thereafter  it  was 
abandoned. 

After  an  interval  of  more  than  a decade  your 
Observer  is  not  so  sure  that  this  action  was  wise. 
At  least  the  schedule  served  as  a guide  to  young 
physicians  and  others  who  were  new  in  the  com- 
munity. While  it  had  the  effect  of  leveling  fees, 
it  also  exposed  the  minority  who  were  guilty  of 
overcharging.  It  would  serve  the  same  purpose 
now  and  in  addition  discourage  the  use  of  the 
fee  schedule  adopted  by  the  Medical  Service  of 
the  District  of  Columbia  as  a criterion  for  charges 
in  private  practice.  This  has  been  a disturbing 
development  to  a number  of  physicians. 

Adoption  of  such  a fee  schedule  would  have  a 
further  advantage.  It  could  be  revised  at  inter- 
vals to  meet  the  rising  costs  of  carrying  on  a prac- 
tice. Many  physicians  charge  the  same  fees' as  they 
did  long  before  the  current  inflationary  spiral, 
and  patients  generally  do  not  e.xpect  them  to  in- 
crease their  charges,  which  is,  of  course,  unfair. 

Largely  responsible  for  the  foregoing  com- 
ments was  an  article  forwarded  to  your  Observer 

* See  editorial  in  this  issue  by  Dr.  Walter  Stokes,  Chair- 
man of  the  Grievance  Committee. 


VOL.  XXI,  NO.  3 


Medical  Annals  of  the  District  of  Columbia 


165 


by  Dr.  Allen  S.  Cross  of  Washington  which  ap- 
peared in  the  Orange  (Virginia)  Review  on  Janu- 
ary 3,  1952.  It  seems  that  the  doctors  in  the  com- 
munity were  feeling  the  “pinch”  because  of  their 
low  fees,  and  a meeting  of  the  Orange  County 
Medical  Society  was  called.  The  Society  adopted 
a fee  schedule  increasing  charges  for  professional 
services  and  making  them  public.  Patients  now 
know  what  they  are  expected  to  pay,  which  will 
undoubtedly  eliminate  many  unpleasant  situa- 
tions. 

If  these  observations  stimulate  thought  and 
discussion  of  a matter  of  vital  importance  to 
both  patients  and  physicians  in  the  District  of 
Columbia,  they  will  have  served  their  purpose. 
The  remedy  is  largely  in  the  hands  of  the  doc- 
tors themselves. 

★ 

^ , In  a more  serious  vein  than 

LJOCtO  Ylfl^ 

r-v  ^ your  Observer  would  adopt  were 
Doctors  ' 

he  discussing  the  subject,  Dr. 

James  Sarnoff,  in  the  Bulletin  of  the  Medical 

Society  of  the  County  of  Kings  (New  VTrk)  for 

January,  1952  writes; 

“It  is  often  said  that  a doctor  makes  a difficult  patient- 
To  a certain  extent,  this  is  true  mainly  because  he  is 
aware  of  the  many  possibilities.  During  the  course  of 
his  practice  he  is  apt  to  prescribe  certain  drugs  and  thera- 
peutic measures  in  an  empirical  form  and  for  psychologi- 
cal reasons.  The  lay  patient,  having  confidence  in  his 
doctor,  follows  such  directions  faithfully,  but  when  the 
doctor  is  the  patient,  he  is  apt  be  to  more  skeptical 
about  the  treatment,  even  though  it  might  be  beneficial. 
Nevertheless,  when  the  ailment  is  of  a serious  nature  he 
is  bound  to  abide  by  the  course  of  treatment  when  it  is 
properly  presented  to  him.  .3s  a rule,  however,  most 
doctors  make  ideal  patients  because  of  their  inherent 
understanding  and  appreciation  of  medical  care.” 

Vour  Observer  hopes  that  Dr.  Sarnoff  or  his 
more  serious-minded  readers  will  not  take  offense 
if  he  admits  to  being  mildly  amusetl  at  the  use 
of  the  adjective  “ideal”  in  describing  physician- 
jpatients.  It  stirred  many  memories  of  ailing 
doctors,  most  of  them  on  the  lighter  side.  One 
of  his  earliest  experiences  in  the  medical  field  is 
lillustrative. 


More  years  ago  than  he  would  like  to  admit, 
your  Observer  was  associated  with  a group  of 
physicians  in  a managerial  capacity.  One  of  the 
doctors  in  this  group,  for  whom  he  has  great 
admiration  and  respect,  took  a dim  view  of 
patients  who  fussed  about  their  ailments.  At 
times  his  patience  was  strained  to  the  point 
where  he  became  quite  explosive.  However,  a 
change  came  over  the  good  doctor  when  he  had 
his  operation.  It  was  an  event  to  be  remembered 
by  those  connected  with  the  clinic  and  small 
hospital  over  which  he  presided. 

When  the  surgeon,  who  was  imported  from  a 
nearby  city,  arrived  he  immediately  went  into 
a huddle  with  the  prospective  patient  and  his 
staff.  In  his  usual  authoritative  manner  the  p.p. 
gave  directions  for  the  removal  of  his  appendix. 
Local  anesthesia  had  just  come  into  use  in  major 
surgery  and  that  suited  the  p.p.  first-rate  be- 
cause he  wanted  a ringside  seat  for  his  operation. 

More  than  the  usual  quota  of  physicians  for 
a simple  appendectomy  gathered  in  the  operating 
room  the  morning  of  the  big  event.  I'or  the  first 
time,  in  a reclining  position,  the  patient  (he  was 
no  longer  a p.p.)  directed  the  proceedings.  .3 
mild-mannered  country  doctor,  a good  friend  of 
the  patient,  was  assigned  the  task  of  wiping  his 
itching  proboscis.  All  went  well  and  the  doctor 
was  wheeled  to  his  room  without  untow'ard  inci- 
dent except  for  a roseate  nose,  skinless  about 
the  nostrils. 

Congratulating  himself  on  the  outcome  (he 
was  too  exhilarated  to  notice  what  had  happened 
to  his  nose),  he  decided  to  break  one  of  his  own 
rules,  perhaps  to  show  that  he  was  an  exceptional 
patient.  Liquid  following  an  abdominal  operation 
was  strictly  verboten  but  the  doctor-j)atient  was 
thirsty-— parched  in  fact  -and  who  was  to  say 
him  nay.  Despite  the  protests  of  the  head  nurse 
he  sent  for  some  good  old  soda  poj),  which  he 
downed  with  gleeful  relish,  d'he  inevitable  hap- 
pened. Loud  groanings  were  soon  emanating  from 
the  patient’s  room.  Your  Observer  in  a down- 
stairs office  heard  them  and  was  considerably 
perturbed.  Later,  the  nurse  confided  that  the 


166 


In  and  Out  of  Focus — Observer 


MARCH,  1952 


Reinstatement  of  AM  A Membership 

A member  of  the  AMA  who  has  been  dropped  for 
nonpayment  of  membership  dues  and  who  wishes 
to  have  his  membership  reinstated  would  owe  mem- 
bership dues  for  the  year  in  which  he  became  delin- 
quent and  the  year  in  which  his  membership  was  re- 
instated, l)ut  he  does  not  have  to  pay  membership 
dues  for  the  intervening  years.  For  example:  Dr. 
Blank  was  dropped  in  1951  for  nonpayment  of  1950 
membership  dues.  He  applies  for  reinstatement  of 
his  AM.A  membership  in  1952.  To  bring  about  this 
reinstatement,  he  would  be  required  to  pay  his  1950 
membership  dues  and  membership  dues  for  1952. 
Membership  dues  for  1951  would  not  be  required. 


patient  insisted  that  no  one  had  ever  had  such 
gas  pains.  As  if  this  were  not  enough,  his  nose 
had  assumed  sizable  proportions.  Death  was 
knocking  at  the  door — he  was  sure  of  it.  Of 
course  he  lived  but  it  took  a lot  of  nursing  and 
special  attention. 

The  doctor  and  your  Observer  have  often 
laughed  over  this  episode.  We  agreed  that  there 
is  nothing  which  will  make  the  doctor  more 
sympathetic  toward  his  patients  than  a dose  of 
his  own  medicine. 

Dr.  Sarnoff  continues: 

“When  the  doctor  is  obliged  to  wait  his  turn  in  a 
doctor’s  waiting  room,  he  can  then  appreciate  the  feel- 
ings of  the  patients  who  wait  for  him.  He  is  less  concerned 
when  he  just  accompanies  his  patient  for  consultation, 
but  his  concern  is  greater  when  it  happens  to  be  a mem- 
ber of  his  family  and  especially  himself.  Nevertheless, 
such  an  experience  serves  a good  purpose.  It  gives  the 
doctor  an  opportunity  to  observe  psychologically  the 
different  attitudes  and  behavior  of  some  of  those  waiting 
patients.  Some  remain  in  blank  oblivion  to  their  sur- 
roundings, others  indulge  in  reading  the  assortment  of 
magazines  on  display,  w'hile  still  others  will  scrutinize 
the  other  patients. 

“The  doctor-patient  as  a rule  is  ill  at  ease  when  he 


has  to  wait.  Even  though  he  might  pretend  to  read,  he, 
as  a rule,  keeps  his  ear  tuned  and  his  eyes  alerted  to  see 
and  hear  what  goes  on  in  the  waiting  room  and  to  catch 
a glimpse  of  what  goes  on  behind  the  scenes  when  the 
office  door  opens.  We  are  apt  to  compare  this  office 
routine  with  our  own  unless  we  are  in  distress.  As  a rule, 
the  courtesy  is  extended  to  the  doctor-patient  to  see 
him  shortly  after  he  arrives.  But  this  is  not  always  the 
case,  especially  when  it  happens  that  some  of  these  con- 
sultants hav'e  quite  a few  doctors  as  patients  waiting, 
and  when  the  treatments  consume  a great  deal  of  time. 

“During  this  waiting  period  we  ponder  about  our 
condition,  how  to  present  it,  and  what  stock  to  take  in 
the  doctor’s  opinion,  advice  and  treatment.  When  we 
are  subjected  to  various  modalities  such  as  fluoroscopy, 
electrocardiography,  neurological  and  ocular  tests  and 
receive  the  various  instructions,  we  begin  to  realize  that 
the  fact  that  we  are  doctors  does  not  make  us  any  less 
human  in  our  feelings,  fears  and  anticipations. 

“The  doctor-patient  knows  too  much  and  you  cannot 
tell  him  the  same  white  lies  and  in  the  same  manner  as 
you  would  the  others.  The  greatest  amount  of  tact  is 
necessary  to  avoid  undue  alarm  or  suspicion  with  regard 
to  the  seriousness  of  the  doctor’s  condition.” 

Many  a doctor’s  patient  would  find  the  above 
enjoyable  and  enlightening  reading.  One  can 
imagine  with  what  satisfaction  they  would  learn 
that  doctor-patients,  like  themselves,  become 
“ill  at  ease”  when  they  have  to  wait. 

Dr.  Sarnoff’s  concluding  paragraph  points  to 
the  fact  that,  after  all,  doctors  are  just  as  human 
as  their  patients.  Here  is  his  final  statement: 

“The  doctor  as  a patient  may  have  suffered  greater 
anxiety  during  the  course  of  his  illness  because  of  his 
apprehensive  knowledge  as  a doctor,  but  in  the  end  he 
is  the  gainer.  Not  only  does  he  acquire  a greater  apprecia- 
tion of  his  colleague’s  knowledge  and  skill,  but  he  also 
obtains  a better  yardstick  with  which  to  measure  his 
own  esteem  of  the  great  amount  of  good  that  he  himself 
does  to  relieve  the  suffering  of  his  own  patients.  He  is 
apt  to  become  more  sympathetic  towards  those  he  is 
treating,  realizing  from  his  own  personal  e.xperience  as 
a patient  what  tender  care,  sympathy  and  consideration 
mean  when  one  is  seriously  ill.” 


T.  W. 


c. 


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PHARMACY 

THE  EDUCATIONAL  PROGRAM  IN  PHARMACY 


Charles  W.  Bliven,  M.S. 

Dean,  School  of  Pharmacy,  The  George  Washington  University 


The  current  academic  year  started  with  17,600 
students  enrolled  in  the  74  colleges  and  schools  of 
pharmacy  throughout  the  United  States.  About  4,000 
of  this  number  will  complete  the  requirements  for 
the  Bachelor  of  Science  in  Pharmacy  degree  in  June 
and  will  join  the  102,000  pharmacists  now  making 
their  contribution  as  members  of  the  health  profes- 
sions through  the  many  areas  embraced  by  the  field 
of  pharmacy. 

The  branch  of  the  profession  in  which  the  great- 
est number  of  pharmacists  contribute  to  the  health 
needs  of  the  Nation  is  that  of  the  practice  of  phar- 
macy through  the  51,000  drug  stores  throughout 
the  country.  This  area  alone  employs  about  89,000 
of  the  total  number  of  pharmacists.  The  remaining 
13,000  are  engaged  in  the  pharmaceutical  field  as 
manufacturers,  wholesalers,  medical  service  repre- 
sentatives, educators,  hospital  pharmacists,  and  em- 
ployees of  state  and  Federal  health  and  law 
enforcement  agencies,  or  as  members  of  the  medical 
groups  of  the  armed  services. 

The  academic  training  of  the  pharmacist  is  suffi- 
ciently comprehensive  that  he  can  readily  adapt 
himself  to  any  of  the  various  opportunities  available 
to  him.  Since  his  educational  program  prepares  him 
to  take  his  place  as  a member  of  the  health  profes- 
sions, his  academic  work  includes,  with  but  few 
exceptions,  courses  identical  with  those  found  in 
the  pre-medical  program,  and  some  of  the  courses, 
notably  biochemistry,  pharmacology,  microbiology, 
and  epidemiology  and  public  health,  parallel  those 
of  the  medical  curriculum.  Often  these  courses  are 
taken  simultaneously  with  students  in  medicine. 

4'he  average  4-year  curriculum*  in  {)harmacy  con- 
sists of  about  135  semester  hours  and  is  required  to 
cover  not  less  than  3,200  clock  hours  of  didactic 
and  laboratory  instruction.  .Although  a standardized 
curriculum  for  all  colleges  of  pharmacy  is  not  manda- 
tory, the  undergraduate  curriculum  can  be  con- 


veniently separated  into  3 divisions  as  follows:  (1) 
nonscientific  courses  in  general  education,  (2)  courses 
in  basic  sciences,  and  (3)  professional  courses.  The 
courses  of  the  first  division,  which  comprise  about 
15  per  cent  of  the  total  program,  permit  the  inclu- 
sion of  courses  in  languages,  economics,  social  stud- 
ies, humanities,  and  others  of  a cultural  nature.  The 
division  of  the  basic  sciences  includes  chemistry 
through  the  course  in  biochemistry,  1 year  of  phys- 
ics, at  least  1 year  of  biology  or  equivalent  courses, 
physiology,  and  microbiology.  These  courses  make 
up  about  40  per  cent  of  the  total  curriculum. 

The  professional  courses,  in  which  the  funda- 
mentals of  the  work  in  the  other  divisions  are  ap- 
plied, constitute  the  largest  jmrt  of  the  curriculum, 
about  45  per  cent.  The  w'ork  in  the  professional  area 
may  be  divided  as  follows:  (1)  pharmacy,  (2)  phar- 
maceutical chemistry,  (3)  pharmacology,  (4)  phar- 
macognosy, and  (5)  pharmaceutical  administration. 
Courses  in  pharmacy  make  up  the  greatest  part, 
about  50  per  cent,  of  the  professional  courses.  These 
include  the  calculations  essential  to  pharmacy,  at 
least  1 year  of  the  study  of  the  various  classes  of 
pharmaceuticals  in  the  United  States  Pharmaco- 
poeia and  the  National  Formulary,  1 year  of  dis- 
pensing pharmacy,  and  hospital  pharmacy.  The  cur- 
riculum in  pharmaceutical  chemistry  embraces  the 
work  in  the  chemistry  and  pharmacy  of  inorganic 
and  organic  medicinals,  including  both  the  official 
(those  of  the  U.S.P.  and  the  N.F.)  and  the  unofficial 
products,  many  of  the  latter  being  new  products 
not  yet  accepted  by  the  official  books. 

The  {)rofessional  courses  in  pharmacology  include, 
in  addition  to  general  ])harmacology,  work  in  toxi- 
cology and  in  the  biological  standardization  of  drugs, 
i’harmacognosy  consists  of  the  study  of  the  crude 


* Five  schools  of  ])harmacy  require  .S  years  and  1 school  6 
years  for  graduation. 


167 


168 


Educational  Program  in  Pharmacy — Bliven 


MARCH,  1952 


animal  and  vegetable  drugs,  and  also  more  recently 
the  study  of  insecticides  and  fungicides. 

The  work  in  the  area  of  pharmacy  administration 
has  recently  undergone  modernization,  and  the  re- 
sult has  been  an  increase  in  emphasis  as  well  as  in 
scope.  As  now  constituted,  this  division  of  the  pro- 
fessional work  includes  courses  in  accounting,  law, 
pharmacy  management,  drug  marketing,  and  j)ro- 
fessional  and  ethical  relations. 

Just  as  the  recent  advances  in  medicinal  products 
have  caused  material  changes  in  medical  therapy, 
these  same  changes  have  brought  marked  changes 
in  the  i)ractice  of  i)harmacy.  The  pharmacist  in  his 
prescription  department  is  being  called  on  to  do 
less  compounding  because  these  advances  have 
changed  the  prescribing  habits  of  the  physician. 
The  isolation  of  pure  plant  principles,  the  vast  in- 
crease in  the  number  of  therapeutically  effective 
synthetic  medicinals,  and  the  advent  of  the  anti- 
biotics have  increased  the  number  of  “one-item” 
prescriptions  and,  accordingly,  have  decreased  the 
number  of  “two-or-more-item”  prescriptions.  Thus, 
less  compounding  is  required  of  the  pharmacist  to- 
day than  ever  before  since,  on  the  average,  74  per 
cent  of  the  prescriptions  written  today  are  “one- 
item”  prescriptions. 

The  decreased  emphasis  on  compounding  has  not 
lessened  the  responsibility  of  the  pharmacist.  Today 
he  is  handling  more  potentially  dangerous  drugs 
than  ever  before.  Indeed,  he  is  required  to  stock  a 
greater  number  of  these  drugs  than  ever  before  to 
meet  the  jirescribing  habits  of  the  physician.  To 
meet  the  needs  of  the  physician  the  pharmacist 
is  called  upon  to  answer  an  increasing  demand  for 
information  on  these  new  drugs  and  thus,  while 
required  to  do  less  compounding,  he  is  assuming  an 
equally  important  role  as  consultant  to  the  physician 
who  may  have  difficulty  in  keeping  up,  because  of 
the  demands  on  his  time,  with  the  increased  number 
and  forms  of  theraj^eutic  jjroducts. 

This  change  in  the  practice  of  pharmacy  has,  of 
necessity,  caused  a shift  in  emphasis  within  the 
pharmaceutical  curriculum.  More  time  is  being  de- 
voted to  the  chemistry  and  ])harmacy  and  to  the 
pharmacology  of  these  new  medicinal  agents  in  order 
that  the  pharmacist  will  possess  the  fundamentals 
with  which  to  better  serve  the  physician  in  his  new 
role. 

The  selection  of  students  entering  the  schools 
and  colleges  of  pharmacy  has  received  increased 


attention  during  recent  years.  Personal  interviews 
and  a series  of  predictive  tests  are  frequent  require- 
ments in  these  institutions  and  assure  a lower  mor- 
tality of  those  students  embarking  on  the  heavily 
laden  science  program  of  135  semester  hours.  Too, 
such  a program  of  selection  provides  young  men  and 
women  possessing  the  personal  qualifications  essen- 
tial for  the  successful  practice  of  the  profession. 

Two  national  organizations  provide  leadership  and 
guidance  for  pharmaceutical  education.  The  first, 
the  American  Association  of  Colleges  of  Pharmacy, 
has  provided  valuable  guidance  for  more  than  50 
years,  while  the  American  Council  on  Pharmaceuti- 
cal Education  has  served  as  the  national  accrediting 
body  since  1939.  At  the  present  time  72  of  the  74 
schools  and  colleges  are  accredited  by  the  Council. 
All  schools  have  been  ree.xamined  since  \^’orld  War 
II,  and  a new  classification  of  e.xisting  schools  will 
be  issued  in  July  of  this  year.  The  new  list  will 
classify  schools  on  an  “A-B-C”  basis.  Class  A will 
include  those  schools  having  no  important  deficien- 
cies; Class  B,  those  having  deficiencies  which  may 
be  corrected  promptly  by  administrative  action; 
and  Class  C,  those  schools  having  deficiencies  which 
will  take  considerable  time  and  effort  to  correct. 
A school  falling  in  Class  C will  be  allowed  a period 
not  to  exceed  3 years  to  correct  the  existing  deficien- 
cies or  show  cause  why  it  should  not  be  dropped 
from  the  list  of  accredited  schools. 

Before  a graduate  in  pharmacy  is  permitted  to 
practice,  he  must  meet  the  requirements  of  the  board 
of  pharmacy  in  the  state  in  which  he  may  wish  to 
practice.  To  be  eligible  for  the  written  and  practical 
examinations  required  by  most  boards,  the  applicant 
must  present  evidence  of  graduation  from  an  ac- 
credited college  of  pharmacy  and  in  addition  must 
have  had,  in  most  states,  at  least  1 year  of  practical 
experience  in  a pharmacy. 

Reciprocity  is  practiced  among  the  states  and  the 
District  of  Columbia  (with  the  exception  of  the 
states  of  California,  New  York  and  Florida)  for 
those  aj:)plicants  successfully  meeting  the  require- 
ments of  a given  state  board  and  who  have  practiced 
for  a year  in  the  state  in  which  examined. 

The  Metropolitan  .^rea  of  Washington  is  served 
by  the  George  Washington  Universit}'  School  of 
Pharmacy.  The  school  is  a member  of  the  .\merican 
.\ssociation  of  Colleges  of  Pharmacy  and  is  ac- 

{Continued  on  page  ISO) 


y^l/tciiual  yl/tcetiHp 


Date 

Society  or  Section 

Program 

Place  and  Time 

March  24 

*Anesthesiologists 

See  page  172 

Medical  Society  .Audito- 
rium, 8:00  p.m. 

March  24 

*George  Washington 

Kellogg  Lecture;  “The  Cardiac  Pa- 

Hall  .A,  School  of  Aledi- 

University  School  of 

tient  as  a Surgical  Risk,”  Francis 

cine,  1335  H Street, 

Medicine 

Clark  Wood,  M.D.,  Professor  of 
Medicine,  University  of  Penna. 

N.W.,  8:30  p.m. 

March  24 

Washington  Medical  and 
Surgical 

“The  Surgical  Treatment  of  Cataract,” 
James  Spencer  Dryden,  M.D. 

Case  Report:  C.  W.  Camalier,  Jr.,  M.D. 

Hotel  2400,  6:30  p.m. 

March  27 

*George  Washington 

Kellogg  Lecture:  Treatment 

Hall  .A,  School  of  Medi- 

University  School  of 

.Approach  to  Psychosomatic  Condi- 

cine,  1335  H Street, 

Medicine 

tions,”  Oliver  Spurgeon  English, 
M.D.,  Professor  of  Psychiatry,  Tem- 
ple University 

N.W.,  8:30  p.m. 

March  29 

*Rheumatism 

“Recent  Advances  in  the  Management 
of  Gout;  the  Use  of  Benemid,”  Alex- 
ander Gutman,  M.D.,  Professor  of 
Medicine,  College  of  Physicians  and 
Surgeons,  Columbia  University 

Medical  Society  .Audito- 
rium, 8:00  p.m. 

April  1 

Section  on  Ophthalmol- 
ogy 

Speaker;  H.  Saul  Sugar,  M.D.,  De- 
troit, Mich. 

Kennedy- Warren,  6 p.m. 

April  9 

*Washington  Psychiatric 

Residents’  Night: 

“Psychiatric  Manifestations  in 

Wounded  Men,”  Captain  Doug- 
las Price,  MC,  US.A,  Walter 
Reed  Hospital 

“Some  Considerations  in  the  Treat- 
ment of  -Alcoholism,”  Thomas  E. 
Griffin,  M.D.,  St.  Elizabeths 
Hospital 

Medical  Society  .Audito- 
rium, 8:30  p.m. 

April  21 

OSLER 

Paper:  William  .A.  Howard,  M.D. 
Case  Report:  John  L.  I’arks,  M.D. 

Host:  Dr.  Thomas  McP. 
Brown 

April  26 

Woman’s  Auxiliary  to  the 
Medical  Society 

Dinner  Dance 

Continental  Room,  Ward- 
man  Park  Hotel:  Cock- 
tails, 7 p.m.;  dinner  8 
p.m. 

April  28 

Washington  Medical  and 
Surgical 

“Review  of  the  Treatment  of  Deafness,” 
T.  Erasier  Williams,  AI.D  , .Arling- 
ton, \’a. 

Case  Report:  Harold  Heighes,  .M.D. 

liotel  2400,  6:30  j).m. 

May  7 

*'rHE  Medical  Society  of 
THE  District  of  Colum- 
bia 

.Annual  Business  .Meeting 

.Medical  Society  .Audito- 
rium, 8:00  p.m. 

May  20 

Clinico-Pathological 

Case  Reports:  Theodore  J.  .Abernethy, 
.M.D.,  AND  Wendell  .M,  W'illett, 
.M.D. 

Host:  Dr.  Walter  W.  Boyd 

]W 


Open  meetings 


STEWART  TRUST  CANCER  GRANTS 


'I'hree  W ashington  institutions  have  received  re- 
newal grants  from  the  Alexander  and  Margaret 
Stewart  Trust  to  provide  care  for  needy  cancer 
patients  in  the  Washington  Metropolitan  Area  and 
for  continuation  of  clinical  research  in  cancer.  They 
are  the  District  of  Columbia  Division  of  the  Ameri- 
can Cancer  Society  and  the  Ceorge  W ashington  and 
Ceorgetown  Universities. 

The  District  Cancer  Society  will  use  its  grant  of 
$33,600  to  help  needy  cancer  patients  who  are  not 
eligible  for  assistance  from  the  D.  C.  Health  Depart- 
ment or  through  the  Hospital  Service  Agency.  The 
funds  are  administered  by  the  Cancer  Aid  Plan 
Committee  of  the  Society. 

.•\  total  of  56  patients  received  financial  aid  in 
1951  from  the  original  Stewart  Trust  grant.  Funds 
advanced  or  authorized  for  these  patients  amounted 
to  $20,987. 

Mr.  Walter  S.  Pratt,  Jr.,  Chairman  of  the  Cancer 
Aid  Plan  Committee,  states  that  since  experience 
under  the  Plan  is  still  quite  limited,  it  is  difficult  to 
estimate  the  probable  number  of  applications  this 
year.  However,  he  says  it  seems  likely  that  requests 
for  aid  will  range  from  $3,500  to  $4,000  monthly  in 
1952. 

.Application  for  assistance  from  the  Cancer  .Aid 
Plan  must  be  made  by  a licensed  physician  practic- 
ing in  Metropolitan  W’ashington.  Further  details 
regarding  the  Plan  and  its  operation  can  be  secured 
by  writing  or  telephoning  the  Cancer  Society 
headquarters,  1415  Eye  Street,  N.W.,  Executive 
3692. 

Two  grants  for  care  and  clinical  research  in  can- 
cer have  been  received  by  the  Ceorge  W'ashington 
University.  In  both  cases  the  grants  are  designed  to 
helj)  and  comfort  persons  whose  illness  from  cancer 
indicates  they  are  incurable.  The  Eund  has  awarded 
$25,000  for  home  care  of  patients  too  ill  to  come  to 
the  clinic  for  treatment  but  not  ill  enough  to  require 
hospital  care.  .An  additional  $20,184  has  been 
awarded  for  research  to  evaluate  methods  of  treat- 
ing cancer  patients  who  are  beyond  help  by  routine 
surgical  or  X-ray  therapy. 

Poth  grants  will  continue  projects  in  progress 
previously  supported  by  the  Stewart  Fund  at  the 
Ceorge  Washington  University  Cancer  Clinic  under 
the  direction  of  Dr.  Calvin  T.  Klopp. 

Fmder  the  home-care  program  patients  able  to 


pay  and  those  unable  to  pay  for  service  receive 
visits  from  physicians  and  nurses,  necessary  medi- 
cines, appliances  and  housekeeping  aid  arranged  for 
by  the  Clinic’s  social  service  worker.  The  service 
spares  the  costs  of  hospital  care  to  the  patient  and 
the  community  and  also  permits  the  patient  to  be 
with  his  family,  a source  of  great  consolation  on 
both  sides. 

The  grant  of  $20,184  will  permit  the  continuation 
of  work  by  Dr.  Jeanne  Bateman  on  development  and 
evaluation  of  methods  of  treating  cancer  patients 
who  can  no  longer  be  helped  by  further  surgery  or 
irradiation.  Certain  drugs  do  benefit  cancer  patients, 
but  are  never  curative.  .Among  these  are  nitrogen 
mustards  and  vitamin  antagonists.  By  devising  bet- 
ter methods  of  administering  these  drugs  and  ad- 
ministering them  together  with  antibiotics,  it  has 
been  possible  to  help  some  terminal  cancer  patients 
by  relieving  pain  and  occasionally  transforming  an 
inoperable  cancer  into  one  which  can  be  successfully 
removed. 

.A  gift  of  $25,000  from  the  Stewart  Trust  to  the 
Ceorgetown  University  Medical  Center  to  carry  on 
the  Home  Care  Service  for  the  calendar  year  1952 
is  the  third  annual  grant  of  that  sum  to  be  awarded 
to  Ceorgetown. 

The  Ceorgetown  home-care  program,  begun  in 
January,  1950,  provides  the  equivalent  of  hospital 
care  in  terms  of  medical,  nursing  and  social  serv- 
ices for  those  preterminal  and  terminal  cancer  pa- 
tients who  may  desire  to  remain  at  home,  or  those 
who  are  unable  to  afford  or  obtain  hospitalization 
because  of  cost  or  lack  of  hospital  beds,  by  returning 
patients  to  their  homes  when,  in  the  opinion  of 
physicians,  they  no  longer  need  hospitalization. 

In  the  calendar  year  1951  the  service  carried  33 
cases  on  its  rolls,  of  which  10  were  held  over  from 
the  previous  year.  The  remaining  23  were  accepted 
from  a total  of  82  cases  referred  for  home  care  during 
the  year. 

Patients  with  varying  stages  of  cancer  use  the 
service,  and  some  patients  are  totally  bedridden. 
With  the  aid  of  a fully  equipped  station  wagon,  the 
Ceorgetown  home-care  staff  is  able  to  perform  many 
extraordinary  bedside  services,  such  as  intravenous 
therapy  and  blood  transfusions. 

Provision  is  made  for  the  readmission  of  patients 
to  the  Ceorgetown  University  Hospital  as  necessary. 


170 


VOL.  XXI,  NO.  3 


Medical  Annals  of  the  District  of  Columbia 


171 


The  hospital  records  are  left  open  during  the  home- 
care  period,  and  the  case  is  recorded  as  if  the  patient 
is  actually  in  the  hospital  building. 

The  maximum  load  of  20  patients  is  maintained 
by  the  service  at  all  times.  Private  physicians  wish- 


ing the  Georgetown  Medical  Center  to  participate 
in  the  care  of  patients  have  been  invited  to  refer  pa- 
tients to  the  service.  The  director  of  the  Home 
Care  Service  may  be  reached  through  the  Home 
Care  Secretary,  Ordway  4000,  Extension  469. 


FCC  APPROVAL  FOR  MEDICAL  DIATHERMY  EQUIPMENT 


Following  is  some  pertinent  information  relative 
to  the  proper  operation  of  medical  diathermy  equip- 
ment after  June  20,  1952.  Present  and  prospective 
operators  of  diathermy  equipment  should  familiarize 
themselves  with  the  rulings  of  the  Federal  Communi- 
cations Commission. 

Section  18.51  of  the  Commission’s  Rules  provides 
that  diathermy  equipment  manufactured  prior  to 
July  1,  1947  may  continue  to  be  operated,  wdthout 
type  approval  by  the  Commission  or  certification 
by  a competent  engineer,  until  June  30,  1952,  pro- 
vided that  no  harmful  interference  is  caused  to 
authorized  radio  services. 

After  June  30,  1952,  type  approval  or  certification 
will  be  necessary  for  continued  use  of  such  equip- 
ment. Procedures  for  certification  by  a competent 
engineer  that  a machine  is  capable  of  meeting  the 
requirements  of  the  rules  of  the  Commission  and 
for  FCC  type  approval  are  set  forth  in  Sections 
18.11-18.16  of  the  Commission’s  Rules.  In  order  to 
be  capable  of  certification,  a machine  must  operate 
on  one  of  the  frequencies  set  forth  in  Section  18.11 
with  spurious  and  harmonic  emissions  reduced  to 
limits  prescribed  in  Section  18.11(b),  or,  in  lieu 
thereof,  must  be  operated  within  the  confines  of  a 
shielded  room  or  space  in  conjunction  with  a power 
line  filter,  a rectified  and  filtered  power  supply,  and 
with  spurious  and  harmonic  emissions  reduced  to  the 
limits  prescribed  in  Section  18.12  (b). 

Certain  types  of  diathermy  machines  may  be 
modified  to  conform  to  the  Commission’s  Rules. 
However,  since  each  machine  will  require  individual 
treatment,  it  may  be  impossible  to  state  that  any 
particular  non-conforming  unit,  from  an  engineering 
I standpoint,  may  be  economically  modified  to  comply 
therewith. 

.'\  change  in  frequency  to  one  of  the  bands  set 
I forth  in  Section  18.11  (a)  would  not  in  itself  neces- 
' sarily  be  sufficient  to  assure  com[)liance  with  the 
Commission’s  Rules  since  Section  18.11  (b)  requires 

I 


that  any  radiations  on  frequencies  other  than  those 
specified  in  Section  18.11  (a)  shall  be  limited  to  a 
maximum  of  25  microvolts  per  meter  at  a distance 
of  1,000  feet  or  more  from  the  diathermy  equipment 
causing  such  radiations. 

The  Commission  does  not  maintain  a file  of  tech- 
nical information  relating  to  the  modification  of 
particular  diathermy  units.  The  manufacturer  of 
such  equipment  or  a competent  radio  engineer  may, 
however,  be  in  a position  to  render  assistance  in  this 
matter. 

Registration  of  diathermy  equipment  with  the 
FCC  was  a wartime  measure  and  is  no  longer  re- 
quired. 

Diathermy  machine  operators  are  normally  re- 
sponsible for  taking  steps  to  eliminate  interference 
caused  to  radio  reception,  irrespective  of  the  type 
approval  status  of  the  interfering  diathermy  ma- 
chine; however,  an  exception  to  this  rule  has  been 
made  in  cases  of  interference  to  receivers  arising 
from  direct  intermediate  frequency  pick-up  by  such 
receivers  of  the  fundamental  frequency  emissions 
of  type  approval  or  certified  diathermy  equipment 
operating  on  prescribed  fundamental  frequencies  and 
otherwise  in  accordance  with  the  rules. 

MEMBERSHIP 

The  following  applicants  for  membership  were 
duly  elected  to  membershij)  at  the  meeting  of  the 
Executive  Board,  January  28,  1952,  in  accord  with 
Amendment  XI,  Section  2,  of  the  Constitution  and 
By-laws  of  the  Society. 

Associate  Members 

Augusto  .\guilera,  371‘>  South  Dakota  .\venue,  N.E. 
Cornelius  J.  Burns,  Prince  Georges  General  Ilosijital,  Chev- 

erly,  Md. 

Louis  R.  Lang,  8641  Colesville  Road,  Silver  Spring,  Md. 
Morris  Perry,  81 14  New  IIami)shire  .4 venue.  Silver  Spring,  Md. 


I 


I 


The  Second  Army  Surgeon,  Brigadier  General 
Alvin  L.  Gorby,  and  a group  of  specialists  will  con- 
duct a series  of  orientation  conferences  for  Army 
Medical  Service  Reserve  Officers  in  the  Second 
Army  area  during  March,  1952.  Following  is  the 
itinerary: 


!March  15 

Cleveland 

March  16 

Cincinnati 

March  22 

Philadelphia 

March  23 

Richmond 

:March  29 

Pittsburgh 

March  30 

Baltimore 

Following  previous  jjolicy  the  Second  Army  is 
taking  the  orientation  conferences  to  the  field  so 
as  not  to  infringe  on  the  professional  time  of  Medical 
Reserve  Officers  by  calling  them  to  Army  head- 
quarters. A further  convenience  is  that  they  are 
being  held  on  weekends  with  a starting  time  of 
1:30  p.m.  Reserve  medical  officers  should  contact 
their  ORC  unit  instructors  for  complete  details, 
including  agenda  and  speakers. 

The  program  for  the  next  meeting  of  the  Wash- 
ington Society  of  Anesthesiologists  was  received  too 
late  to  appear  in  the  Calendar  of  Medical  Meetings 
in  the  February  issue.  The  Society  will  meet  in  the 
Medical  Society’s  auditorium,  March  24,  at  8 p.m. 
Four  10-minute  talks  have  been  arranged,  each  one 
to  be  followed  by  brief  discussion.  Subjects  and 
speakers  are: 

“The  Present  Status  of  Muscle  Relaxant,”  Dr.  C.  Herbert 
Spencer,  Fellow  in  Anesthesiology,  George  Washington  Uni- 
versity School  of  Medicine. 

“Preliminary  Survey  of  Relationship  of  Obstetric  .\nalgesia 
and  .\nesthesia  to  Asphyxia  Neonatorum,”  Dr.  Morton  Ber- 
kow.  Resident  in  Anesthesia,  Veterans  Administration. 

“The  Use  of  Antihistamines  in  the  Prevention  of  Trans- 
fusion Reactions,”  Dr.  Seymour  .Mpert,  Instructor  in  Anes- 
thesiology, George  Washington  F^niversity  School  of  Medi- 
cine. 

“The  Management  of  Cardiac  Arrest,”  Dr.  Salomon  Al- 
bert, of  Beirut,  Lebanon  Fellow  in  Anesthesiology,  George 
Washington  University  School  of  Medicine. 


The  Department  of  Medicine  of  Georgetown  Uni- 
versity School  of  Medicine  is  sponsoring  a Post- 
graduate Course  in  Clinical  Electrocardiography, 
which  began  on  March  6 and  will  continue  in  weekly 
two-hour  sessions  for  12  weeks.  The  lecturers  are 
Dr.  Joseph  M.  Barker,  Associate  Professor  of  Clini- 
cal Medicine,  and  Dr.  W.  Proctor  Harvey,  Instructor 
in  Medicine.  The  registration  fee  is  $50.00. 

Donation  fees  at  three  cancer  detection  centers 
in  Washington  have  been  increased  from  $15  to  $20. 
The  price  change,  recommended  by  the  D.  C.  Divi- 
sion of  the  American  Cancer  Society  and  approved 
by  the  District  Medical  Society,  was  necessitated 
because  of  the  rising  cost  of  medical  services  offered. 
Examinations  at  the  cancer  detection  centers  are 
given  to  patients  at  cost.  The  new'  fees  will  be  ap- 
plied at  Garfield  Memorial  Hospital,  George  Wash- 
ington University  Cancer  Clinic,  and  Georgetown 
University  Medical  Center. 

At  the  meeting  of  the  Executive  Board  of  the 
Medical  Society  of  the  District  of  Columbia,  January 
28,  the  following  physicians  were  appointed  to  serve 
as  chairmen  of  committees  for  the  23rd  Annual 
Scientific  Assembly: 

Program:  Dr.  Ralph  M.  Caulk 
Scientific  E.xhibit:  Dr.  Alfred  A.  J.  Den 
Public  Health  Exhibit:  Dr.  James  J.  Feffer 
Radio,  TV  and  Motion  Pictures:  Dr.  Frank  S. 

Ashburn 

Social  Affairs:  Dr.  Lawrence  A.  Rapee 
Attendance:  Dr.  William  T.  Gibb,  Jr. 

Women’s  Activities:  Dr.  Helen  Gladys  Kain 
Selected  to  serve  on  the  new  Committee  on  Medi- 
cal Education  Fund  were:  Dr.  Alan  F.  Kreglow, 
Chairman;  Dr.  Frederic  G.  Burke  and  Dr.  Robert  B. 
Nelson,  Jr. 

Another  new  committee  has  been  created  to  study 
and  recommend  revisions  in  the  Constitution  and 
By-laws.  The  members  of  the  Committee  are:  Dr. 
Walter  Freeman,  Chairman;  Dr.  William  M.  Bal- 
linger and  Dr.  Frank  D.  Costenbader. 


172 


VOL.  XXI,  NO.  3 


Medical  Annals  of  the  District  of  Columbia 


173 


Dr.  Duane  C.  Richtmeyer  was  named  to  succeed 
Dr.  Arch  L.  Riddick  on  the  Grievance  Committee. 

Dr.  Frederick  O.  Coe  was  nominated  to  succeed 
himself  as  a \dce  President  of  the  Washington  Acad- 
emy of  Sciences. 

The  Board  voted  to  accept  the  invitation  of  the 
D.  C.  Pharmaceutical  Association,  e.xtended  by  its 
President,  Mr.  h'.  Royce  Franzoni,  to  hold  a joint 
meeting  with  the  Medical  Society.  The  meeting 
will  be  held  in  conjunction  with  the  Annual  Business 
Meeting  of  the  Society  on  May  7. 

In  a discussion  of  membership  dues  from  phy- 
sicians who  resign  from  the  Society,  the  consensus 
of  the  Board  was  that  anyone  who  had  not  paid  his 
dues  by  January  1 and  who  resigned  after  that 
date  and  before  June  30,  be  required  to  pay  dues 
for  the  first  half  year;  if  he  resigned  after  June  30, 
he  be  required  to  pay  dues  for  the  full  year. 

Competition  for  the  1952  Kenfield  Memorial 
Scholarship  opened  March  1.  The  American  Hearing 
Society  is  administrator  of  the  annual  award  to  a 
prospective  teacher  of  lipreading  to  the  hard  of 
hearing,  .'\pplications  should  be  mailed  before  May  1 
to  Miss  Rose  Feilbach,  1157  Columbus  Street,  Arling- 
ton, Va. 

.Applicants  for  the  scholarship  must  be  well  ad- 
justed individuals  with  pleasing  personality,  legible 
lips,  a good  speech  pattern,  and  no  unpleasant  man- 
nerisms. Graduation  from  college  with  a major  in 
education,  psychology,  and  or  speech  is  a require- 
ment. Winners  of  the  award  are  entitled  to  take 
a teachers’  training  course  in  lipreading  from  any 
normal  training  teacher,  school  or  university  in  the 
United  States  offering  a course  acceptable  to  the 
Society’s  Teachers’  C'ommittee.  Physicians  are  urged 
to  inform  qualified  persons  of  this  scholarship. 

Six  members  of  the  teaching  staff  of  Georgetown 
University  School  of  Medicine  attended  and  took 
part  in  the  meetings  of  the  Southern  Section  of 
the  American  Federation  for  Clinical  Research  and 
the  Southern  Society  for  Clinical  Research  in  .At- 
lanta, Ga.,  January  18  and  19.  They  were:  Dr. 
Harold  Jeghers  and  Dr.  Hugh  H.  Hussey,  Professor 
I and  .Associate  Professor  of  Medicine,  resi)ectively, 
and  Drs.  Edward  1).  Freis,  Laurence  H.  Kyle,  Wil- 
liam P.  Walsh  and  Robert  T.  Kelley,  all  of  the 
I Department  of  Medicine.  Dr.  Freis  was  elected  \'ice 


President  of  the  Southern  Society  for  Clinical  Re- 
search. 

Members  of  the  group  presented  the  following 
papers  before  the  Southern  Section  of  AFCR:  “The 
Effect  of  Acute  Reduction  of  Arterial  Pressure  Losing 
Hexamethonium  on  the  Manifestations  of  Congestive 
Heart  Failure  in  Man”  by  Drs.  Kelley,  Thomas  F. 
Higgins  and  Freis,  and  “The  Treatment  of  Bar- 
biturate Poisoning  by  Hemodialysis”  by  Drs.  Walsh, 
Kyle,  Paul  D.  Doolan  and  Jeghers. 

The  following  papers  were  presented  before  the 
Southern  Society  for  Clinical  Research,  the  last  two 
by  title  only:  “Hemodynamic  Alterations  in  Acute 
Myocardial  Infarction:  Mechanism  of  Cardiogenic 
‘Shock’,”  Drs.  Freis,  Harold  W.  Schnaper  and  Robert 

L.  Johnson;  “A  Simplified  Method  of  Management 
of  Hypertensive  Toxemias  of  Pregnancy  Losing  a 
Purified  Extract  of  Veratrum  Viride,”  Dr.  Frank  A. 
Finnerty;  and  “Studies  on  the  Effects  of  Modified 
Human  Globin,”  Drs.  Kyle,  W.  C.  Hess  and  Walsh. 

At  the  annual  meeting  of  the  Washington  Psy- 
chiatric Society,  January  10,  Dr.  Zigmond  M.  Leben- 
sohn  assumed  the  presidency  of  the  Society  for  1952. 
Dr.  Leo  Bartemeier,  President  of  the  American  Psy- 
chiatric Association,  was  the  guest  speaker.  His 
paper  on  “The  Attitude  of  the  Patient”  was  dis- 
cussed by  Dr.  Dexter  M.  Bullard,  Medical  Director 
of  Chestnut  Lodge,  Dr.  Edward  J.  Stieglitz,  special- 
ist in  geriatrics,  and  Dr.  Preston  .A.  McLendon, 
Professor  of  Pediatrics,  George  Washington  Uni- 
versity School  of  Medicine. 

.At  the  request  of  President  Lebensohn,  Dr.  Barte- 
meier presented  certificates  of  commendation  to 
three  Past  Presidents  of  the  Society,  Drs.  .Addison 

M.  Duval,  Robert  T.  Morse  and  Xorman  Q Brill. 

New  officers  elected  are: 

Dr.  Henry  P.  Laughlin,  President-elect;  Dr.  .Seymour  J. 
Rosenberg,  Secretary;  Dr.  Marshall  dcO.  Ruflin,  Treasurer; 
Drs.  Robert  .\.  Cohen  and  Douglas  Noble,  Counci',  members. 

The  George  M.  Kober  Medical  Society  held  a 
dinner  meeting,  January  21,  at  the  .Army-Xavy 
Club.  Dr.  J.  Gordon  Bell,  the  essayist,  [tresented  a 
paper  on  "Some  Useful  Procedures  in  Plastic  Sur- 
gery.” Dr.  Jed  W.  Pearson  was  host  for  cocktails. 

.At  the  dinner  meeting,  February  18,  Dr.  Russel 
S.  Page  s{)oke  on  “Recent  Prends  in  Otolaryn- 
gology.” Dr.  John  C.  Murphy  was  host  for  cocktails. 


174 


News  and  Personals 


MARCH,  1952 


Calendar  of  Meetings, 

January  16-Febru.\ry  15 

January  16 

Section  on  Gastroenterology 

Registered  X-ray  Technicians  of 

January  17 

Section  on  Radiology 

W’ashington 

Health  Section,  United  Community 

February  6 

Executive  Board,  Woman’s  Aux- 

Services 

iliary 

January  19 

Washington  Psychoanalytic  Society 

February  7 

Section  on  Neurology  and  Psychi- 

January  21 

Board  of  Censors 

atry 

Grievance  Committee 

Executive  Committee,  Gallinger 

January  22 

Section  on  General  Practice 

Hospital 

D.  C.  Society  of  Anesthesiologists 

February  9 

W’ashington  Psychoanalytic  Society 

January  24 

Special  Committee  on  Teaching 

February  11 

Committee  on  Blood  Banks 

Technics 

Committee  on  Public  Relations 

Medical  Care  Services  for  Civil  Defense 

W’ashington  Orthopedic  Club 

Graduate  Nurses’  Association 

Graduate  Nurses’  Association 

January  25 

Subcommittee  of  Medical  Care 

February  12 

Membership  Luncheon 

January  28 

Executive  Board 

Medical  Officers’  Reserve  Units 

Committee  on  Cooperation  with 

Lay  Society,  Diabetes  Association  of 

D.  C.  Bar  Association 

D.  C. 

January  30 

Committee  on  Public  Policy 

February  13 

Committee  on  Public  Policy 

W'ashington  Gynecological  Society 

W’oman’s  Auxiliary 

February  5 

Grievance  Committee 

Washington  Heart  Association 

WMmen’s  Medical  Society 

February  14 

Subcommittee  on  Child  Welfare 

Members  cf  the  Washington  Clinical  Club  met 
for  dinner,  March  4,  at  the  Army-Navy  Club.  Dr. 
Donald  H.  Deeper,  Jr.  gave  a case  report  on  “A 
Complication  of  Acute  Appendicitis.” 

The  George  Washington  University  Medical  So- 
ciety held  its  third  meeting  of  the  season,  January 
30.  The  guest  speaker  was  Dr.  L.  Kraeer  Ferguson, 
Professor  of  Surgery  of  Woman’s  Medical  College  of 
Pennsylvania  and  Graduate  School  of  Medicine  of 
the  D^niversity  of  Pennsylvania.  His  subject  was 
“Malignant  and  Inflammatory  Lesions  of  the 
Colon.” 

Dr.  Fred  R.  Sanderson  was  host  to  the  Clinico- 
Pathological  Society  at  his  home  in  Kenwood,  Feb- 
ruary 19.  Two  case  reports  were  presented  for  dis- 
cussion: “Influence  of  Endometriosis  on  Fertility,” 
Dr.  Henry  L.  Darner,  and  “A  Case  of  Cardiac 
Arrest,”  Dr.  Weston  Bruner. 

The  Washington  Psychoanalytic  Society  met  in 
the  Medical  Society’s  Library  on  Saturday,  Feb- 
ruary 9.  Dr.  Lawrence  C.  Kolb,  of  the  Mayo  Clinic, 
Rochester,  Minn.,  presented  a paper  on  “Psychology 


of  the  Amputee:  Phantom  Phenomenon  and  Pain.” 
Discussants  were  Drs.  O.  R.  Langworthy  and  Doug- 
las Noble. 

Dr.  Caroline  Jackson  addressed  an  open  meeting 
of  the  Women’s  Medical  Society,  March  4,  in  the 
Medical  Society’s  auditorium.  Her  subject  was 
“Some  Factors  in  Fetal  Mortality.” 

The  D.  C.  Division  of  the  American  Cancer  So- 
ciety has  moved  from  Fifteenth  Street  into  new 
offices  at  1415  Eye  Street,  N.W.  The  telephone 
number.  Executive  3692,  is  unchanged. 

The  United  Cerebral  Palsy  Association  of  Wash- 
ington is  now  located  at  1730  Eye  Street,  N.W. 
The  headquarters  will  also  serve  as  offices  for  the 
Southern  Region  of  the  national  organization,  which 
is  located  in  New  York  City.  The  telephone  number 
of  the  W ashington  office  is  Republic  4978. 

The  American  Medical  Association  has  recently 
established  a new  Committee  on  Nervous  and  Men- 
tal Diseases  under  the  chairmanship  of  Dr.  Lauren 
H.  Smith  of  Philadelphia.  Dr.  Francis  M.  Forster, 


VOL.  XXI,  NO.  3 


Medical  Annals  of  the  District  of  Columbia 


175 


Professor  and  Head  of  the  Department  of  Neurology 
of  Georgetown  University  School  of  Medicine,  repre- 
sents Neurology  on  this  Committee. 

The  District  of  Columbia  Dental  Society  observed 
National  Children’s  Dental  Health  Day  at  the  Shore- 
ham  Hotel,  February  4.  Table  clinics  were  held  in 
the  afternoon.  Dr.  Arthur  Dick,  dental  surgeon  and 
physician,  an  Active  member  of  the  District  Medical 
Society,  presided  at  one  of  the  table  clinics  and  led 
discussion  on  “Tumors  in  the  Maxillofacial  Area  in 
Children.” 

Dr.  Edward  H.  Cushing  resigned  his  position  as 
Assistant  Chief  Medical  Director  for  Research  and 
Education  of  the  Veterans  Administration,  March  1. 
Medical  Director  Joel  T.  Boone  has  appointed  as  his 
successor.  Dr.  George  Marshall  Lyon,  founder  and 
director  of  the  extensive  radioisotope  program  in 
VA  hospitals.  Dr.  Lyon  was  senior  research  assistant 
to  Dr.  Cushing. 

Dr.  Lyon,  a native  of  Pennsylvania,  received  his 
medical  degree  from  Johns  Hopkins  FIniversity  in 
1920.  During  World  War  I he  served  as  an  officer 
in  the  Chemical  Warfare  Service.  During  World  War 
II  he  rose  to  the  rank  of  Captain  in  the  Navy 
Medical  Corps.  He  was  safety  advisor  and  repre- 
sentative of  the  Surgeon  General  of  the  Navy  on  the 
staff  of  the  Commander  of  the  Joint  Task  Force  One 
at  Bikini.  He  is  a Fellow  of  the  American  Medical 
Association,  the  American  College  of  Physicians, 
and  the  American  Academy  of  Pediatrics  and  a 
diplomate  of  the  American  Board  of  Pediatrics. 

Dr.  Charlotte  Donlan  assumed  her  new  duties  as 
Director  of  the  Cancer  Detection  Clinic  of  George 
Washington  University  School  of  Medicine,  Feb- 
ruary 1.  The  Detection  Clinic  is  part  of  the  Uni- 
versity’s Cancer  Clinic  under  the  general  supervision 
of  Dr.  Calvin  T.  Klopp. 

Complete  physical  examinations  are  given  at  the 
clinic,  including  blood  count,  urinalysis,  chest  X-ray, 
proctoscopic  examination,  and  for  women  a pelvic 
examination  and  vaginal  smear  examination.  Clinics 
are  scheduled  for  Tuesdays,  Thursdays,  and  Satur- 
I days,  from  8:30  a.m.  to  noon.  The  patient  is  ex- 
I pected  to  contribute  S2()  to  cover  costs  of  the 
■ examination. 

I Dr.  Donlan  is  also  C'linical  Instructor  in  Radiology 


at  the  Medical  School  and  radiotherapist  at  the 
Hospital.  She  was  formerly  Director  of  the  Bureau 
of  Cancer  Control  of  the  District  Health  Depart- 
ment. She  is  a graduate  of  Hunter  College  and  of  the 
Woman’s  Medical  College  of  Pennsylvania. 

Dr.  Augusto  Aguilera  attended  the  Fourth  In- 
ternational Congress  on  Mental  Health  in  Mexico 
City  in  December,  1951.  He  was  appointed  chairman 
for  one  of  the  technical  sessions  on  Mental  Health 
and  the  Maladjusted  Child.  He  also  presented  a 
paper  on  “School  Failure,  Psychiatric  Implications” 
before  a Working  Group  which  dealt  with  “Human 
Relations  in  the  School.”  For  his  services  Dr.  Agui- 
lera, with  other  participants  in  the  Congress,  re- 
ceived a diploma  and  Medal  of  Distinguished  Visitor 
from  the  Mayor  of  the  City  of  Mexico. 

Dr.  Aguilera,  an  Associate  member  of  the  District 
Medical  Society,  is  a psychiatrist  on  the  staff  of 
Catholic  University. 

Dr.  Edgar  W.  Davis,  Professor  of  Thoracic  Surgery 
at  Georgetown  University  School  of  Medicine,  was 
in  Birmingham,  Alabama,  February  15  and  16,  ad- 
dressing the  Southern  Chapter  of  the  International 
College  of  Surgeons.  He  presented  a paper  on  “The 
Surgical  Treatment  of  Mitral  Stenosis”  on  February 
15  and  participated  in  a Symposium  and  Panel 
Discussion  on  Surgical  Treatment  of  Tuberculosis 
the  following  day. 

Dr.  John  R.  Pate,  Director  of  the  Southwest 
Health  Center,  was  cited  by  the  District  League  of 
Women  Voters,  January  29,  for  his  “sense  of  re- 
sponsibility as  a citizen  of  Washington”  and  for  his 
“outstanding  achievements  in  providing  public 
health  services  to  the  people  of  Southwest  Washing- 
ton.” Dr.  Pate  has  been  Director  of  the  Health 
Center  since  1948.  He  was  honored  during  the 
League’s  annual  All-Day  School,  held  in  the  Shore- 
ham  Hotel. 

Dr.  Philip  A.  Caulfield,  former  Chief  of  Staff  of 
Providence  Hospital,  has  been  named  Chairman  of 
the  Medical  Staff  Division  of  the  new  Providence 
Hospital  Building  Fun  1 Cami)aign.  His  unit  will  be 
asked  to  raise  $112,500  of  the  million-dollar  drive 
for  building  funds.  Serving  with  Dr.  C'aulficld  will 
be  Dr.  Thomas  F.  Collins,  now  Chief  of  Staff,  and 


176 


News  and  Personals 


MARCH,  1952 


I 


Drs.  Robert  U.  Cooper,  Leo  B.  Gaffney  and  Samuel 
Zola,  all  on  the  Hospital  staff.  The  public  fund- 
raising efforts  will  begin  about  April  1.  Mr.  John  A. 
Reilly,  President  of  the  Second  National  Bank,  is 
the  Campaign’s  General  Chairman. 

Dr.  Donald  Stubbs  addressed  a meeting  of  phy- 
sicians in  Salisbury,  Md.,  January  14.  His  topic  was 
“The  Anesthesiologist  in  General  Therapy.”  On  Feb- 
ruary 4 he  spoke  to  a group  of  anesthesiologists  in 
Baltimore  on  “The  Treatment  of  Acute  Clinical 
Emergency.” 

Dr.  Robert  G.  McCorkle,  Jr.,  has  been  named  the 
year’s  outstanding  surgical  house  physician  at 
George  Washington  University  Hospital.  The  selec- 
tion is  made  through  secret  ballot  by  fellow  interns 
and  resident  physicians.  This  distinction  gives  the 
select  the  privilege  of  a two  weeks’  visit,  with  ex- 
penses paid,  to  an  institution  of  his  choice,  which, 
for  Dr.  McCorkle,  will  be  the  Massachusetts  General 
Hospital  and  Lahey  Clinic  in  Boston. 

Dr.  McCorkle  received  his  rredical  degree  from 


Baylor  University  in  1946.  After  a year’s  internship 
at  Santa  Rosa  Hospital,  he  was  inducted  into  the 
Navy  and  served  on  the  surgical  service  of  the  U.  S. 
Naval  Hospital  in  San  Diego,  Calif.  In  July  1949  he 
came  to  George  Washington  Hospital  as  a resident 
physician  in  surgery.  He  is  a Resident  member  of 
the  District  Medical  Society. 

The  following  physicians  have  moved  from  W ash- 
ington  and  have  resigned  their  Associate  member- 
ship in  the  Medical  Society: 

Dr.  Robert  L.  Brickhouse,  whose  address  now  is 
301  Rivermont  Avenue,  Lynchburg,  \'a. 

Dr.  Alvin  J.  Cummins,  on  the  staff  of  the  Hospital 
of  the  University  of  Pennsylvania  in  Philadelphia, 
where  he  plans  to  remain  indefinitely. 

Dr.  Paul  Heller,  who  is  with  the  \'eterans  .Ad- 
ministration Hospital  in  Omaha. 

.A  former  .Active  member  of  the  Society,  Dr. 
Barbara  Moulton,  has  transferred  to  Associate  be- 
cause she  is  now  {practicing  in  Normal,  Illinois. 
Her  address  is  815  South  Fell  .Avenue. 


CALEND.AR  OF  SPEAKERS 


The  following  members  of  the  Medical  Society  of  the  District  of  Columbia  have  addressed  lay  groups  during 
the  past  several  weeks.  The  Society  maintains  a Speakers  Bureau,  sponsored  by  the  Committee  on  Public  Rela- 
tions, through  which  requests  for  speakers  for  lay  groups  can  be  filled. 


Date 

Speaker 

Subject  or  Title 

Organization 

January  16 

Dr.  William  P.  .Argy 

Cerebral  Palsy:  a General  Sur- 

1). C.  Society  for  Crippled 

vey 

Children,  Inc. 

January  16 

Dr.  Winfred  Overholser 

Mind  and  Its  Behavior 

Science  Eorum  of  Unitarian 

Laymen’s  League 

January  22 

Dr.  Richard  H.  Fischer 

Pregnanediol 

D.  C.  Society  of  Medical  Tech- 

nologists 

January  .10 

Dr.  Julius  Schreiber 

Danger  Signals  in  Child  Be- 

Potomac .Association  of  Co- 

havior 

operative  Teachers 

February  4 

Dr.  Cyril  .A.  .Schulman 

Early  Cancer  Detection 

.Michigan  Park  Citizens’  .As- 

sociation 

February  20 

Dr.  Victor  .Alfaro 

Oto-rhino-laryngological  .As- 

1). C.  Society  for  Crippled 

pects  of  Cerebral  Palsy 

Children,  Inc. 

March  5 

Dr.  Dscar  B.  Hunter,  Jr. 

Etiological  Eactors  in  Cere- 

D. C.  Society  for  Crippled 

bral  Palsy 

Children,  Inc. 

March  10 

Dr.  Sidney  Berman 

The  Challenge  of  .Adolescence 

.Alice  Deale  Junior  High 

School  Parent-Teachers  .As- 
sociation 


\ 


S 


\ 


I VOL.  XXI,  NO.  3 


Medical  Annals  of  the  District  of  Columbia 


177 


Roger  Morrell,  a sophomore  student  at  George 
W ashington  University  School  of  Medicine,  was  the 
second  prize  winner  in  a medical  essay  contest  spon- 
sored for  medical  students  in  the  United  States  and 
Canada  by  Schering  Corporation.  The  contest  is 
held  yearly  for  the  purpose  of  encouraging  research 
in  medical  literature.  The  topic  assigned  for  the 
essays  this  year  was  “The  Use  of  Steroid  Hormones 
in  the  Treatment  of  Arthritis.” 

Mr.  Morrell,  who  is  the  son  of  Colonel  and  Mrs. 
Jacque  C.  Morrell,  of  8 O.xford  Street,  Chevy  Chase, 
Md.,  was  presented  with  a check  for  $500  in  the 
office  of  the  Dean  of  the  School  of  Medicine,  Dr. 
W'alter  A.  Bloedorn.  The  check  was  awarded  to  Mr. 


Morrell  on  February  13  by  Dr.  M.  W'illiam  Amster, 
of  Bloomfield,  N.  J.,  Chairman  of  the  Awards  ('om- 
mittee. 

“Having  a Baby,”  by  Ruth  Carlson,  is  the  title  of 
a new  pamphlet  (No.  178)  in  a series  of  pamphlets 
[rublished  by  the  Public  Affairs  Committee,  Inc., 
a nonprofit,  educational  organization  with  offices  at 
22  East  38th  Street,  New  York  16,  N.  Y.  The 
pamphlet  sells  at  cost,  25  cents  a copy.  Illustrated 
with  pen  and  ink  sketches,  it  presents  the  subject 
in  cheerful  discourse.  It  was  prepared  in  coopera- 
tion with  the  Maternity  Center  Association.  .\n 
e.xcellent  reading  list  is  included. 


BOOK  REVIEWS 


Dementia  Praecox  or  The  Group  of  Schizophre- 
nias. Eugen  Bleuler,  M.I).  Translated  by  Joseph 
Zinkin,  M.D.  Foreword  by  Nolan  I).  C.  Lewis,  M.D. 
Price,  $7.50.  Pp.  548.  New  York:  Internal.  Univ.  Press, 
1950. 

Dementia  Praecox;  The  Past  Decade’s  Work 
and  Present  Status — A Review  and  Evaluation. 

Leopold  Bellak,  M.D.  Foreword  by  Winfred  Over- 
holser,  M.D.  Price,  $10.00.  Pp.  471,  with  illustrations. 
New  York:  Grune  & Stratton,  1948. 

Every  year  about  18,000  new  cases  of  poliomyelitis 
attack  our  population.  The  disease  is  of  such  a devastat- 
ing character  and  is  fraught  with  so  many  tragedies  that 
universally  papers  give  a great  deal  of  attention  to  it. 
Local  papers  report  carefully  every  new  case  of  polio. 
The  fate  of  the  victims  appears  to  be  a matter  for  all  to 
be  concerned  over,  for  everyone  feels  he  may  be  the  next 
victim.  Yet  there  is  another  disease,  not  physical  but 
mental,  which  attacks  every  year  a much  greater  number 
of  victims,  and  the  effects  are  even  more  tragic  and  more 
devastating  than  those  of  polio.  This  is  the  disease 
schizof)hrenia,  commonly  known  as  dementia  praecox. 
While  many  cases  of  polio  can  recover  without  any 
particular  residuals,  and  probably  acquire  immunity 
against  further  attacks,  it  is  rare  for  schizophrenia  to  sub- 
side without  leaving  some  evidence  of  the  attack,  and 
the  chances  of  recurrence  are  very  great.  Many  patients 
with  schizophrenia  remain  in  the  hospital,  a responsi- 
bility of  the  community  and  a tremendous  burden  on 
the  taxpayers,  but,  more  important  jTt,  an  emotional 
strain  on  the  family  of  the  patients  involverl. 

j When  Bleuler’s  Textbook  of  Psychiatry  first  aj)pearcd, 
it  was  a welcome  addition  to  psychiatric  literature  be- 
cause it  was  considerably  different  from  the  formulation 

i given  by  Kraepelin.  For  the  first  time  psychology  was 

I 


approached  from  a purely  psychiatric  point  of  view  and, 
therefore,  differed  both  from  the  conventional  view  of 
Kraepelin  and  the  Wundtian  psychology  which  held 
sway  at  that  time.  Bleuler’s  Textbook  was,  however,  not 
available  to  English-speaking  people  until  1923,  when 
the  late  Dr.  A.  .\.  Brill,  an  erstwhile  pupil  of  Bleuler, 
gave  the  English-speaking  public  a translation  of  the 
book.  The  reviewer  recalls  that  on  the  appearance  of  it, 
he  told  Brill  that  his  next  obligation  should  be  the  trans- 
lation of  Bleuler’s  Schizophrenia,  since  that  this  would 
be  a great  stimulus  to  further  work  on  schizophrenia. 
This,  however.  Brill  failed  to  do,  and  it  was  not  until  a 
year  ago  that  the  translation  of  Bleuler’s  Schizophrenia 
by  Dr.  Zinkin  appeared  in  English.  The  translation 
may  be  recorried  as  a milestone  in  .American  psychiatry. 

The  discussion  of  the  accessory  sym[)toms  in  Chapter 
11  calls  attention  to  man\^  somatic  manifestations  in- 
cident to  schizophrenia.  It  is  Bleuler’s  Ijelief  that  when 
one  considers  all  the  somatic  symptoms  in  their  totality, 
they  suggest  that  the  disease  is  based  upon  more  funda- 
mental alteration  of  the  brain  or  perhaps  even  of  the 
entire  body,  a view  which  is  not  shared  by  many  leading 
psychiatrists.  He  records  his  observation  of  the  increase 
in  brain  weight  in  proportion  to  the  skull  size,  and  even 
choked  discs  and  pu()illary  disturbances.  .\t  times  the 
bodily  state  may  resemble  that  seen  in  severe  infections, 
while  the  severe  psychic  symptoms  are  sometimes  remi- 
niscent of  those  due  to  increased  intracranial  i)ressure. 
He  points  out  that  in  acute  catatonic  states  jiarticularly 
we  often  find  a coated  tongue,  anorexia  (even  without 
psychogenic  refusal  of  food),  and  poor  assimilation  of 
food;  thus  it  sometimes  hai)i)ens  that  the  patient’s 
physical  and  nutritional  condition  deteriorates  ra[)iflly, 
quite  independently  of  any  motor  strain;  the  movements 
become  tremulous.  Often  such  conditions  are  ac- 


178 


Book  Reviews 


MARCH,  1952 


companied  by  a slight  rise  of  temperature.  Up  to  5 per 
cent  of  albumin  in  the  urine  has  been  found  in  stuporous 
cases.  Amenorrhea  is  frecjuently  observed  in  catatonic 
stupors.  There  may  also  be  found  marked  fluctuations 
in  weight  without  any  definite  relationship,  especially 
to  improvement,  in  the  patient’s  mental  condition.  Food 
intake,  as  well  as  general  intestinal  activity,  is  dependent 
in  schizophrenia  to  the  highest  degree  upon  psychic 
factors.  Delusions  of  poisoning,  negativism,  autism,  agi- 
tation, etc.,  often  prevent  or  render  these  activities 
difficult.  A high  degree  of  oligemia  or  chlorosis  has  been 
found  in  some  catatonic  states.  Definite  abnormalities 
have  been  established  in  the  studies  of  white  blood 
cells.  Disturbances  in  cardiovascular  functions  have 
been  observ^ed.  Even  in  quiet  periods  the  pulse  rate  is 
quite  variable,  while  in  acute  states  the  pulse  variations 
may  be  great  and  quite  sudden.  It  is  not  unusual  to  find 
that  a paranoid  patient  who  is  developing  catatonic 
symptoms  has  a pulse  rate  which  changes  abruptly  sev- 
eral times  during  a single  observation,  e.g.,  from  80  to 
l.IO,  without  any  apparent  reason.  The  vasomotor  system 
may  be  markedly  altered.  In  catatonic  conditions  lividity 
and  cyanosis  are  very  common,  not  particularly  in  the 
hands  and  feet  but  also  in  other  areas.  The  tendency  to 
edema  is  usually  ascribed  to  poor  circulation,  but  it 
must  also  have  other  causes.  We  find  edema  without 
demonstrable  passive  congestion,  and,  conversely, 
marked  degrees  of  passive  congestion  without  edema. 
Patients  also  often  develop  edema  of  the  ankles  and 
legs  and  this  perhaps  is  not  so  surprising  when  one  recalls 
that  patients  stand  for  decades.  Besides  edema,  other 
trophic  disturbances  which  may  be  related  to  the  vaso- 
motor system  are  found  in  schizophrenia.  The  fragility 
of  the  blood  vessels,  which  may  appear  in  many  cases  of 
acute  and  chronic  schizophrenia,  seems  to  indicate  a real 
vascular  lesion.  From  here  we  could  go  on  mentioning  a 
great  many  other  somatic  disturbances,  such  as  disturb- 
ances in  the  function  of  the  sweat  glands,  osteomalacia, 
bone  fragility,  etc.  Just  what  the  connection  is  between 
these  symptoms  and  psychosis  is  as  yet  undetermined. 
Sleep  is  habitually  disturbed;  impotence  and  frigidity, 
spasms  and  intensifications  of  idiomuscular  contractions 
are  quite  common;  fibrillary  contractions  are  sometimes 
noticeable  in  the  facial  muscles. 

Yet  when  all  is  said  and  done,  the  impression  remains 
with  the  reviewer  that  schizophrenia  as  well  as  other 
mental  diseases  are  basically  psychogenic  in  origin.  It 
is  not  difficult  to  see  how  continuous  psychic  preoccupa- 
tion with  bodily  problems  is  bound  to  have  its  effect  in 
producing  functional  disturbances  which,  if  persistent 
and  continued  long  enough,  may  well  lead  to  organic 
changes,  by  which  time  the  condition  cannot  be  helped 
by  psychotherapeutic  encroachments.  One  knows  cases 


of  individuals  who  years  before  they  developed  gastric 
ulcer  have  been  brooding,  melancholy  individuals  dis- 
tinctly of  the  nervous  type  with  consequent  hyper- 
chlorhydria  eventually  leading  to  ulceration.  At  like  level 
are  physical  and  psychic  manifestations  in  mental  dis- 
eases. The  schizophrenia  that  attacks  elderly  people, 
such  as  arteriosclerotic  psychosis  or  senile  psychosis,  is 
basically  not  different  from  the  psychosis  that  attacks 
younger  people.  In  the  former  case  there  may  seem  to  be 
a physical  background  in  the  hardening  of  the  blood 
vessels  or  deterioration  of  the  parenchyma  of  the  brain. 
These  may  be  the  immediate  precipitating  factors,  but 
by  no  stretch  of  imagination  could  we  connect  the  harden- 
ing of  blood  vessels  and  the  softening  of  the  parenchyma 
if  it  were  not  for  the  appearance  of  delusions — more 
particularly  their  nature  and  content.  What  these  physi- 
cal factors  did  was  merely  to  bring  to  the  surface  under- 
lying psychologic  situations,  essentially  pathologic  in 
nature,  which  had  been  lying  dormant  as  long  as  the  body 
integrity  was  not  involved,  but  with  the  weakening  of 
the  physical  defenses  these  factors  came  to  the  surface 
and  gave  rise  to  the  mental  symptoms.  Take  such  a 
typically  organic  brain  disease  as  dementia  paralytica; 
there  is  no  doubt  here  of  the  physical  destruction  of  the 
brain  tissue.  The  frontal  lobes  are  phylogenetically  the 
latest  to  develop  and,  therefore,  the  first  to  suffer  from 
the  attack  of  cerebral  lues,  but  no  amount  of  spirochetosis 
can  explain  the  mental  content  found  in  these  patients: 
the  grandiosity  in  one  case,  the  stupor  in  another,  the  ^ 
deterioration  in  a third  case,  and  so  on.  For  the  explana-  I 
tion  of  this  we  have  to  go  back  to  the  earlier  life  of  the  i| 
individual,  to  his  fears  and  dreads,  to  his  wishes  and 
ambitions,  to  his  entire  personality. 

Bleuler’s  book  appeared  in  1911  and  it  wasn’t  trans-  ' 
lated  into  English  until  recently.  The  edition  offered  is  an 
exact  translation  of  what  we  knew  of  schizophrenia  in 
1911.  Much  new  has  been  added  to  our  clinical  knowledge 
of  the  condition,  and  this  is  taken  up  most  competently 
by  Dr.  Beliak’s  book.  Dr.  Beliak’s  work  brings  the  | 
material  up  to  date  and  additionally  discusses  a number 
of  features  not  touched  upon  by  Bleuler.  This  concerns 
modern  treatment  of  schizophrenia:  insulin  therapy,  use 
of  metrazol,  electric  shock  treatment,  as  well  as  the 
psychologic  and  psychotherapeutic  studies.  A full  chap- 
ter is  given  to  psychotherapy,  which  we  do  not  find  in 
Bleuler’s,  and  another  chapter  to  discussion  of  dementia 
praecox  in  childhood.  Beliak’s  book  has  an  immense 
number  of  references,  and  it  was  quite  a remarkable 
feat  to  bring  the  best  of  the  material  extant  between  the 
covers  of  one  book.  It  is  a book  from  the  reading  of 
which  every  physician  could  profit. 

Ben  K.arpm.\n,  M.D. 


VOL.  XXI,  NO.  3 


Medical  Annals  of  the  District  of  Columbia 


179 


An  Atlas  of  Normal  Radiographic  Anatomy.  Isa- 
dora Meschan,  M.A.,  M.D.,  Professor  and  Head  of  the 
Department  of  Radiology,  University  of  Arkansas  School 
of  Medicine,  with  the  assistance  of  R.  M.  F.  Farrer- 
Meschan,  M.B.,  B.S.  (Melbourne,  Australia).  Price, 
$15.00.  Pp.  593,  with  1044  illustrations  on  362  figures. 
Philadelphia:  Saunders,  1951. 

This  is  an  excellent  volume  for  students,  interns, 
residents,  and  general  practitioners  since  the  author  has 
written  and  illustrated  his  work  with  that  purpose  in 
mind.  As  stated  in  his  preface,  he  includes:  (1)  basic 
morbid  anatomy  as  it  is  applicable  to  radiography;  (2) 
the  manner  in  which  the  routine  projections  employed 
in  radiography  are  obtained;  (3)  a concept  of  the  films 
so  obtained;  (4)  the  anatomic  parts  best  visualized  on 
these  views;  (5)  changes  with  growth  and  development; 
and  (6)  some  of  the  more  common  variations  of  normal. 
He  gives  a brief  discussion  of  the  mechanics  and  physics 
of  the  production  of  X-rays  and  films.  Each  area  is  dis- 
cussed with  reference  to  the  relation  of  the  various 
structures  and  the  necessity  for  the  various  views  that 
are  part  of  the  radiologist’s  armamentarium.  Special 
studies,  including  the  use  of  radiopaque  material,  are 
briefly  discussed,  indications  and  contraindications  being 
stated. 

This  book  was  not  written  for  the  radiologist’s  use 
but  should  be  a part  of  every  student’s,  intern’s,  or 
resident’s  library,  since  it  so  well  fills  a void  in  a field 
in  which  they  have  had  so  little  study  and  training. 

Sigmund  Newman,  M.D. 

RALPH  ANDRE  QUICK,  M.D. 
(1882-1952) 

Dr.  Ralph  A.  Quick,  practicing  physician  in  Ar- 
lington County,  Virginia,  for  more  than  40  years, 
died  suddenly,  January  20,  1952,  at  his  home,  4725 
North  Rock  Spring  Road,  Arlington,  Va. 

Dr.  Quick  was  born  in  Ashburn,  Loudoun  County, 
Virginia,  September  21,  1882.  He  attended  public 
schools  in  Washington  and  graduated  from  old  Cen- 
tral High  School.  He  received  his  medical  degree 
from  George  Washington  University  in  1908. 

Following  graduation  Dr.  Quick  opened  his  offices 
in  Clarendon,  Virginia,  w’here  he  practiced  continu- 
ously until  his  death,  except  for  a tour  of  service 
with  the  American  Red  Cross  in  Europe  during 
World  War  I. 

He  was  a Fellow’  of  the  American  Medical  Associa- 
tion and  a member  of  the  Arlington  County  (Vir- 
ginia) Medical  Society  and  the  George  M’ashington 


University  Medical  Society.  He  had  been  an  Associ- 
ate member  of  the  District  Medical  Society  since 
1936.  He  was  also  affiliated  with  the  Columbia  Lodge 
No.  285,  A.F.  and  A.M.,  the  Kiwanis  Club,  and  the 
Clarendon  Baptist  Church. 

Surviving  are  his  wife,  Mrs.  Myrna  Miles  Quick, 
a daughter.  Miss  Jeanne  A.  Quick,  both  living  at 
home,  and  a son,  John  G.  Quick,  who  resides  at 
6119  North  12th  Street,  Arlington.  He  also  leaves 
two  sisters,  Mrs.  Christine  Sramek  and  Mrs.  Mary 
Bowman,  and  a brother,  G.  Willard  Quick,  all  of 
Arlington. 

HOWARD  HENRY  HOWLETT,  M.D. 
(1883-1952) 

Dr.  Howard  H.  Howlett,  first  physician  to  prac- 
tice in  Silver  Spring,  Maryland,  died  January  19, 
1952,  at  his  home,  928  Sligo  Avenue,  Silver  Spring, 
after  an  extended  illness. 

The  son  of  John  Henry  and  Jane  Elizabeth  How- 
lett, Dr.  Howlett  was  born,  November  8,  1883,  in 
Washington,  D.  C.  After  graduating  from  the  public 
schools  of  Washington,  he  studied  medicine  at  George 
Washington  University,  receiving  his  degree  in  1907. 
He  practiced  medicine  in  Walkerton,  Va.,  for  five 
years  and  then  moved  to  Silver  Spring,  where  he  was 
the  only  physician  for  several  years. 

During  World  War  I he  was  regimental  surgeon 
with  the  61st  Infantry,  5th  Division,  and  with  the 
84th  Division.  His  duties  took  him  to  France  and 
Belgium;  he  also  served  with  the  Army  of  Occupa- 
tion in  Luxemburg  and  Germany  from  1917  to  1920. 
He  was  commissioned  Captain  in  the  Regular  Army 
in  1920  and  assigned  to  Walter  Reed  Hospital,  where 
he  remained  until  he  resigned  his  commission  two 
years  later.  Thereafter  he  resumed  his  practice  as  a 
general  practitioner  in  Silver  Spring;  he  became  ill 
about  10  months  ago. 

Dr.  Howlett  had  courtesy  privileges  at  most  of 
the  Washington  hospitals.  He  was  a member  and 
Past  President  of  the  Montgomery  County  (Mary- 
land) Medical  Society.  He  was  a Fellow  of  the  Ameri- 
can Medical  Association,  the  Medical  and  Chirurgi- 
cal  Faculty  of  Maryland,  the  Southern  Medical 
Association,  the  George  Washington  University 
Medical  Society,  and  the  Silver  Spring  Academy  of 
Medicine.  He  was  elected  to  Associate  membership 
in  the  Medical  Society  of  the  District  of  Columbia  in 
1927. 


180 


Medical  Annals  of  the  District  of  Columbia 


MARCH,  1952 


Dr.  Howlett  was  also  a member  of  a number  of 
fraternal  orf!;anizations,  including  Silver  Spring 
Lodge  No.  215,  A.F.  and  A.M.,  Maryland  Royal 
•Arch  Chapter  No.  58,  Silver  Spring  Lodge,  B.P.O.E., 
the  American  Legion,  and  the  Washington  Branch 
of  the  Fifth  Division  Society,  C.S.  Army. 

'Fhe  only  close  survivor  is  his  wife,  Mrs.  Lina 
Walker  Howlett,  of  the  home  address. 

WILLIAM  EDWARD  TORREY,  JR., 
A.B.,  M.D. 

(1919-1951) 

Dr.  W.  Edward  Torrey,  Jr.,  who  only  last  year 
resigned  his  membership  in  the  District  Medical 
Society  after  moving  to  Moorestown,  New  Jersey, 
died,  December  2b,  1951,  following  injuries  received 
in  an  auto  accident  the  evening  of  December  26, 
when  his  car  was  struck  by  a motorist  fleeing  police. 
'I'he  tragedy  occurred  just  outside  the  Burlington 
County  Hospital  in  Mount  Holly,  N.  J. 

Dr.  Torrey  was  born  in  Philadelphia,  Penna., 
.April  2,  1919,  the  son  of  W.  Edward  and  Elsie 
( Jordon  Torrey.  He  received  both  hisA.B.  and  M.D. 
degrees  from  the  University  of  Pennsylvania,  the 
latter  in  1945. 

Immediately  following  his  graduation  from  Medi- 
cal School,  Dr.  Torrey  accepted  a commission  as 
Lieutenant  in  the  Medical  Corps  of  the  L^.  S.  Navy, 
where  he  served  during  World  War  1 1,  from  1945 
to  1947.  He  interned  at  the  U.  S.  Naval  Medical 
Center  in  Bethesda  for  a year,  in  the  course  of  which 
he  studied  tropical  medicine  and  ei)idemiology  at  the 
Medical  School.  He  was  assigned  to  submarine- 
diving duty  as  a medical  specialist  and  served  in 
both  the  Atlantic  and  Pacific  theatres  of  action. 

In  1947,  after  being  discharged  from  the  Navy, 
he  became  associated  with  Drs.  Jacob  Kotz  and 
Morton  S.  Kaufman  in  the  Columbia  Medical  Build- 
ing, specialists  in  obstetrics  and  gynecology.  He 
continued  his  training  in  this  specialty  as  resident 
physician  at  the  Pennsylvania  Hosjiital  in  Phila- 
delphia. 

Dr.  4'orrey  was  an  Active  member  of  the  Medical 
Society  of  the  District  of  Columbia  in  1948,  and  an 
.Associate  member  from  1949  to  1951.  He  was  a 
Fellow  of  the  American  Medical  Association,  and  a 
member  of  the  American  Physicians’  .Art  .Association 
and  the  Piersol  .Anatomical  Society  of  the  University 
of  Pennsylvania. 


Dr.  Torrey  leaves  his  wife,  Mrs.  Carrieanna  Frye  i 
Torrey  and  three  small  children.  His  home  and  office 
were  located  at  244  West  Main  Street,  Moorestown, 

N.  J. 

Enzymatic  Debridement  of  War  Wounds— Spittler  et  al 

(Continued  from  page  135) 

to  be  little  difference  in  the  effect  of  SK-SI)  and 
trypsin  in  the  type  of  wound  treated  in  this 
series. 

BIBLIOGRAPHY 

1.  Tillett,  VV.  S.,  .\nd  G.A.RNER,  R.  L.:  J.  Exper.  Med., 

1933,  58,  485. 

2.  G.\rner,  R.  L.,  .\nd  Tillett,  \V.  S.:  Ibid.,  1934,  60,  239 

and  255. 

3.  Sherry,  S.,  Tillett,  \V.  S.,  .\nd  Christensen,  L.  R.: 

Proc.  Soc.  Exper.  Biol.  & Med.,  1948.  68,  179. 

4.  Tillett,  \V.  S.,  Sherry,  S.,  .\nd  Christensen,  L.  R.: 

Ibid.,  1948,  68,  194. 

5.  Tillett,  W.  S.,  .\nd  Sherry,  S.:  J.  Clin.  Investigation, 

1949,  28,  173. 

6.  Sherry,  S.,  Johnson,  .\.,  .and  Tillett,  \V.  S.:  Ibid., 

1949,  28,  1094. 

7.  Tillett,  W.  S.,  .and  others:  .\nn.  Surg.,  1950,  131,  12. 

8.  Re.ad,  C.  T.,  .and  Berry,  E.  B.:  J.  Thoracic  Surg.,  1950, 

20,  384. 

9.  Sherry,  S.,  Tillett  W.  S.,  and  Read,  C.  T.  : Iliid.,  1950 

20,  393. 

10.  Miller,  J.  M.,  Ginsberg,  M.,  Luhn,  R.  J.,  and  L.ang, 

P.  H.:  J.A..M.A.,  1951,  145,  620. 

11.  Reiser,  H.  G.,  Roettig,  L.  C.,  and  Ccrtis,  G.  M.: 

Tryptic  deliridement  of  tibrinojiurulent  empyema,  in 
Surgical  Forum.  Proceedings  of  the  Forum  Sessions, 
36th  Clinical  Congress  of  .\merican  College  of  Surgeons, 
Boston,  Mass.,  October,  19.50.  Philadelphia;  Saunders, 
1951. 

12.  Kunitz.  M.:  J.  Gen.  Physiol.,  1950,  33,  349. 

13.  Hazlehcrst.  G.  X.:  J.  Immunol.,  19.50,  65,  185. 

Educational  Program  in  Pharmacy — Bliven 

(Continued  from  page  168) 

credited  as  a Class  A school  by  the  .American  Council 
on  Pharmaceutical  Education.' 

•A  program  of  limited  enrollment  is  dictated  by 
the  capacity  of  the  laboratories.  In  addition  to  the 
usual  credentials,  a series  of  predictive  tests  and  an 
interview,  as  outlined  above,  are  required  of  all 
applicants  who  are  eligible  for  admission  on  the 
basis  of  their  jirevious  scholastic  achievements. 

’ .Vccreditation  Manual,  5lh  ed.  Chicago:  The  .\merican 
Council  on  Pharmaceutical  Education,  1951. 


MEDICAL  ANNALS 

of  the 

DISTRICT  OF  COLUMBIA 


VOLUME  XXI  April,  1952  NUMBER  4 


DYSTOCIA  DUE  TO  FETAL  ABNORMALITIES* 


YSTOCIA  due  solely  to  abnor- 
malities of  the  fetus  occurs  infrequently.  P'or  that 
reason  few  comprehensive  reports  are  available. 
In  general,  only  isolated  case  reports  have  ap- 
peared in  the  literature.  During  the  past  3 years 
several  instances  of  dystocia  due  to  fetal  abnor- 
malities have  been  encountered  at  the  Gallinger 
Municipal  Hospital  and  the  George  Washington 
University  Hospital.  Some  of  the  more  inter- 
esting of  these  problems  will  be  presented. 

A general  classification  of  this  type  of  dystocia 
is  as  follows:  (1)  dystocia  due  to  excessive  size 
of  the  fetus,  (2)  dystocia  due  to  abnormalities 
of  presentation,  (3)  dystocia  due  to  single  mon- 
sters and  that  related  to  abnormal  enlargement 
of  the  body  of  the  fetus,  and  (4)  that  concerned 
with  double  monsters.^  The  problem  of  severe 
polyhydramnios  is  also  considered,  because  ap- 
proximately 50  per  cent  of  all  patients  with  that 
condition  will  have  anomalous  infants.^  In  this 
presentation  each  of  the  foregoing  types  of  dys- 
tocia is  discussed  with  the  exception  of  dystocia 
arising  from  malpresentations  of  normally  formed 
fetuses. 


* Delivered  at  the  Twenlj'-second  .Annual  Scientific  .\s- 
, semhly  of  the  Medical  Society  of  the  District  of  Columbia, 
j October  1951. 


ROBERT  H.  BARTER,  M.D. 

Associate  Professor  of  Obstetrics  and  Gynecology,  George  Washing- 
ton University  School  of  Medicine 


Excessive  Size  of  the  Eetus 

The  most  common  form  of  dystocia  to  be 
considered  is  that  due  to  excessive  size  of  the 
fetus.  In  many  instances  the  large  fetus  may  not 
be  normal,  since  the  condition  is  common  in  in- 
fants of  diabetic  or  prediabetic  mothers,^  or  when 
erythroblastosis  is  present.  However,  the  ma- 
jority of  infants  weighing  over  4,500  grams  (9 
lbs.  14  oz.)  are  normal  except  for  excessive  size. 
Predisposing  factors  are  large  parents,  multi- 
parity, advancing  age  and  rarely  prolonged  preg- 
nancy.^ The  most  important  cause  is  probably 
that  of  excessive  growth  during  a normal  period 
of  gestation.  The  exact  cause  for  the  increased 
development  is  unknown.  In  almost  all  instances 
in  which  difficulty  is  encountered  in  women  with 
normal  pelves  the  most  serious  dystocia  occurs 
with  the  shoulders  of  the  fetus.  In  infants  of 
excessive  size  the  shoulder  circumference  may  be 
greater  than  a similar  measurement  of  the  fetal 
head.  With  a large  fetus  the  head  may  be  de- 
livered with  reasonable  ease,  but  it  may  be  ex- 
tremely difficult  or  impossible  to  deliver  the 
shoulders  without  serious  damage  to,  or  death 
of  the  infant.^ 

It  is  essential  that  the  diagnosis  of  a fetus  of 
excessive  size  be  made  prior  to  the  delivery  of 


I 


182 


Dystocia  due  to  Fetal  Abnormalities — Barter 


APRIL,  1952 


the  head.  Aids  in  establishing  the  diagnosis  are 
(Da  history  of  diabetes,  the  possibility  of  eryth- 
roblastosis, or  a history  of  previous  large  infants, 
(2)  apparent  excessive  size  of  the  infant  upon 
abdominal  palpation  in  the  absence  of  poly- 
hydramnios or  twins,  and  (3)  failure  of  fetal 
descent  in  a patient  with  a normal  pelvis  who  is 
having  satisfactory  labor.  The  diagnosis  by 
means  of  X-ray  films  alone  may  be  misleading. 
However,  if  the  pregnancy  has  been  prolonged, 
particularly  in  a large  or  obese  patient,  and  if 
the  fetus  shows  evidence  of  large  size  and  hyper- 
flexion by  means  of  X-ray  films,  one  must  con- 
sider the  possibility  of  an  oversized  fetus.®  Post- 
maturity in  itself  is  no  indication  that  the  fetus 
will  be  of  abnormal  size." 

The  only  effective  treatment  of  shoulder  dys- 
tocia is  its  prevention.  In  most  instances  in  which 
shoulder  dystocia  has  occurred,  however,  hind- 
sight points  out  the  fact  that  at  some  time  dur- 
ing the  course  of  labor  cesarean  section  might 
well  have  been  considered.  Only  rarely  is  cesar- 
ean section  employed  with  a large  fetus  as  the 
indication. 

When  shoulder  dystocia  occurs,  all  of  one’s 
obstetrical  ingenuity  must  be  used  if  a normal 
living  infant  is  to  be  delivered.  Various  manipu- 
lations aimed  at  rotation  of  the  fetus  in  an  at- 
temf)t  to  deliver  one  shoulder  have  been  advo- 
cated. If  one  shoulder  can  be  delivered,  usually 
the  i)osterior,  the  second  shoulder  ordinarily  can 
be  delivered  with  relatively  little  more  effort. 
Occasionally  cleidotomy  may  have  to  be  em- 
ployed, but  such  a procedure  should  have  de- 
creasing acceptance. 

With  antenatal  fetal  death,  shoulder  dysto- 
cia is  greatly  increased  because  of  the  lack  of 
tone  in  the  fetal  body,  which  interferes  with  the 
expulsive  efforts  of  the  uterus.  Rigor  mortis  of 
the  fetus,  which  on  rare  occasions  manifests  it- 
self after  an  intrauterine  demise,  is  an  obvious 
cause  of  shoulder  dystocia. 

Whenever  dystocia  is  encountered  after  de- 
livery of  the  head,  one  must  be  aware  of  the  pos- 
siblity  of  a monster.  The  latter  diagnosis  can  be 


established  by  getting  an  examining  hand  past 
the  impacted  shoulders  (if  such  is  possible),  or 
by  means  of  X-ray  films.  Shoulder  dystocia  must 
be  avoided  rather  than  treated.  When  it  does 
manifest  itself  the  fetal  loss  is  excessive.  The 
presence  of  serious  birth  injuries  is  high  in  the 
infants  who  manage  to  survive  the  manipula- 
tions necessary  to  free  the  shoulders.®  The  more 
liberal  but  judicious  use  of  cesarean  section  when 
treating  patients  with  fetuses  of  excessive  size 
will  save  many  infant  lives,  and  will  prevent  an 
untold  amount  of  physical  and  psychic  trauma 
to  the  mother.  Following  a traumatic  delivery  of 
an  oversize,  stillborn  fetus,  voluntary  sterility 
occurs  in  many  marriages. 

Single  Monsters 

One-half  to  1 per  cent  of  all  newborn  infants 
have  1 or  more  congenital  anomalies.®’  The 
incidence  may  be  higher  than  that  in  patients 
with  toxemia  of  pregnancy, “ or  those  with 
twins. Most  of  the  anomalies  of  single  monsters 
are  concerned  with  the  central  nervous  system. 
Anencephaly,  hydrocephaly,  microcephaly,  and 
spina  bifida  are  the  most  common  disorders.  Of 
extreme  importance  is  the  fact  that  in  many  fe- 
tuses a combination  of  anomalies  is  found. 

With  microcephaly,  dystocia  is  usually  absent. 
With  anencephaly,  dystocia  relative  to  the  fetus 
itself  is  uncommon,  but  instances  have  been 
reported  where  shoulder  dystocia  has  been  a 
factor.  The  latter  may  be  caused  by  an  incom- 
pletely dilated  cervix  which  allows  the  small 
head  but  not  the  shoulders  to  descend,  or  by 
true  shoulder  dystocia  as  a result  of  excessive 
development  of  the  body  of  the  fetus. 

The  infant  with  spina  bifida  may  occasionally 
be  a source  of  major  difficulty.  The  finding  of  a 
spina  bifida  during  the  course  of  a breech  de- 
livery should  automatically  warn  one  of  the 
likelihood  of  hydrocephaly  in  the  same  infant, 
for  16  per  cent  of  infants  with  spina  bifida  have 
an  associated  hydrocephalus  (fig.  1).^® 

The  hydrocephalic  fetus  occasions  the  most 
concern.  One  must  be  sure  of  the  diagnosis  before 


VOL.  XXI,  NO.  4 


Medical  Annals  of  Ihc  District  of  Columbia 


183 


the  institution  of  any  treatment,  and  the  diag- 
nosis is  at  times  difficult  to  make.  The  latter  is 
particularly  true  when  the  fetus  presents  as  a 
breech,  as  it  does  in  about  30  per  cent  of  the 
cases. With  the  distended  head  presenting,  the 
diagnosis  is  more  apt  to  be  made  than  if  the 


Fig.  1.  Stillborn  infant  with  multi[)le  congenital  defects, 
including  hydroce|)halus,  spina  bifida,  exstrophy  of  the  bladder, 
congenital  absence  of  the  external  genitalia,  and  bilateral 
talipes  varus.  Breech  ])resentation;  delivered  without  de- 
com|)ression  of  the  aftercoming  head.  Birth  weight,  -S  lbs. 
8 oz.  (2,495  grams). 

breech  presents.  In  prenatal  e.xaminations  dis- 
parity between  the  enlarged  head  and  the  pelvic 
inlet  may  manifest  itself  rather  early.  In  later 
pregnancy  hydrocephaly  should  be  kept  in  mind 
when  the  head  cannot  be  made  to  descend  into 
the  jtelvis.  Pelvic  e.xamination  may  reveal  open 
suture  lines  and  bulging  fontanelles  as  well  as 


easy  compressibility  of  the  cranial  vault.  An 
additional  diagnostic  point  is  that  with  a hydro- 
cephalic head  the  suture  lines  may  spread  during 
a uterine  contraction  instead  of  approximating, 
as  is  customary. 

kixtreme  enlargement  of  the  head  makes  the 
diagnosis  easy.  With  breech  presentations,  the 
disorder  is  less  a{)t  to  be  noticed  during  early 
examinations.  The  diagnosis  of  hydrocephaly  by 
X-ray  examination  is  more  difficult  with  breech 
presentation  because  of  the  possibility  of  greater 
divergent  distortion.  Disparity  between  the  out- 
line of  the  thin  skull  and  the  facial  features, 
gaping  suture  lines,  and  a globular  shape  of  the 
head  will  help  to  establish  the  X-ray  diagnosis 
even  when  marked  distortion  is  present.'^ 

That  the  uterus  may  rupture  before  or  during 
labor  from  overdilatation  of  the  lower  uterine 
segment  must  be  constantly  kept  in  mind  in  the 
management  of  the  patient  with  a hydrocephalic 
vertex  presentation.'^  Ordinarily  the  patient  may 
be  allowed  to  go  into  labor,  and  after  effacement 
and  partial  dilatation  of  the  cervix  has  occurred 
the  excess  cerebrospinal  fluid  may  be  removed 
by  doing  an  intraventricular  tap  with  a trocar 
or  a spinal  needle.  Such  may  be  done  without 
interfering  with  any  religious  principles.'®  After 
an  adecjuate  amount  of  fluid  has  been  released 
a Willett  clamp  with  an  attached  I lb.  weight 
may  be  applied  to  the  fetal  scalp  to  assist  in  the 
descent  of  the  decompressed  head.  In  cases  in 
which  the  fetal  head  is  extiemely  large  the  tap 
may  have  to  be  done  through  a relatively  un- 
dilated cervix.  Version  and  extraction  of  a hydro- 
cephalic fetus  is  not  only  unnecessary,  but  rup- 
ture of  the  already  thinned-out  lower  uterine 
segment  may  result  from  such  manipulations. 
Cesarean  section  is  rarely  if  ever  indicated  in  a 
patient  who  has  a known  hydrocephalic  infant, 
since  the  delivery  can  be  more  safely  accom- 
{)lished  through  the  birth  canal. 

If  the  hydrocephalic  infant  presents  as  a 
breech,  labor  may  be  allowed  to  commence  nor- 
mally and  the  delivery  of  the  fetus  to  the  head 
carried  on  in  the  customary  manner.  If  one  is 


184 


Dvstocia  due  to  Fetal  Abnormalities — Barter 


APRIL,  1952 


unable  to  deliver  the  aftercoming  head,  a needle 
or  a trocar  may  be  introduced  through  the  palate 
or  through  the  occipital  plate  and  the  cerebro- 
spinal fluid  released.  Either  maneuver  is  not 
difficult,  but  perforation  through  the  palate  is 
the  easier  of  the  two.  After  decompression  the 
aftercoming  head  usually  is  no  longer  a dystocia 
problem.  It  is  reemphasized  that  one  must  be 
aware  of  the  high  incidence  of  hydrocephalus  in 
fetuses  presenting  by  the  breech  with  defects  of 
the  spinal  nervous  system. 

The  other  condition  encountered  in  this  cate- 
gory is  that  of  enlargement  of  the  body  of  the 
fetus.  This  form  of  dystocia  is  cpiite  rare.  When 
it  occurs  it  is  usually  due  to  an  atresia  of  the 
lower  urinary  tract,  to  congenital  polycystic  kid- 
neys, or  to  marked  ascites  in  the  hydropic  form 
of  erythroblastosis.  The  diagnosis  may  be  made 
by  means  of  X-ray  films  in  selected  instances 
from  the  “Buddha-like  posture”  of  the  fetus 
(fig.  2)F 

When  delivery  of  the  infant  is  impossible  after 
the  head  or  the  feet  have  been  delivered,  the 
treatment  of  choice  is  aspiration  of  the  distended 
bladder  or  of  the  abdomen.  If  the  head  has  been 
delivered  it  may  be  quite  difficult  to  accomplish 
such  a procedure.  In  some  cases  eventration 
may  have  to  be  done  after  the  fluid  has  been 
aspirated.  In  such  cases  the  greatest  concern 
should  be  directed  to  the  mother,  since  in  prac- 
tically all  of  the  conditions  producing  this  anom- 
aly normal  postnatal  life  for  the  infant  is  impos- 
sible. 

Double  Monsters 

A double  monster  is  delivered  so  infrequently 
that  few  obstetricians  encounter  such  a speci- 
men during  a lifetime  of  practice.  In  general,  the 
literature  contains  only  isolated  instances  of  their 
occurrence.’*’  The  recent  literature  is  devoid 
of  any  large  series  of  such  infants  occurring  in 
any  one  hospital.  Premature  labor  usually  oc- 
curs in  the  presence  of  double  monsters.  I"or 
that  reason  dystocia  from  this  type  of  defective 
fetus  occurs  infrequently.  In  those  cases  in  which 


the  combined  fetal  mass  has  attained  consider- 
able size,  delivery  through  the  birth  canal  may 
be  totally  impossible.  In  the  greatest  majority 
of  patients  with  this  condition  the  antepartum 
diagnosis  can  only  be  made  by  means  of  X-ray 
films.  All  patients  in  whom  a multiple  pregnancy 


Fig.  2.  Infant  with  erythroblastosis  showing  the  typical 
“Buddha-like”  position  of  the  forearms  and  hands  on  the 
distended  abdomen.  Birth  weight.  9 lbs.  (4,082  grams). 

is  suspected  and  any  patient  who  has  an  appar- 
ent polyhydramnios  should  have  antenatal  films 
of  the  abdomen.  The  diagnostic  features  of 
double  monsters  in  X-ray  films  are  (1)  the  fetal 
heads  at  the  same  level,  and  (2)  the  fetal  sjtincs 
closely  parallel  or  convergent  and  not  deviating 
from  their  fi.xed  alignment.  With  a normal  mul- 
tiple pregnancy  the  heads  usually  are  at  dift'erent 


Medical  Annals  of  the  District  of  Columbia 


185 


V 

VOL.  XXI,  NO.  4 

levels,  and  the  spines,  if  parallel,  are  far  apart. 
The  spines  may  also  be  found  in  different  relative 
positions  on  different  films  with  normal  multiple 
pregnancies. 

The  treatment  of  the  patient  with  a known 
monster  depends  primarily  upon  the  size  of  the 
anomalous  double  fetus.  As  mentioned,  most 
conjoined  fetuses  of  this  type  cause  little  if  any 
difficulty  in  delivery,  because  premature  labor  is 
initiated  spontaneously  while  the  size  of  the 
individual  components  is  still  small.  If  the  preg- 
nancy continues  past  the  34th  week,  serious 
dystocia  may  result.  In  some  cases  the  size  of 
the  monster  is  not  as  important  as  the  presenta- 
tion or  the  specific  type  of  monster.  In  figure  3 
the  specimen  weighed  only  5 lbs.  5 oz.,  but  vag- 


jt  Fig.  3.  Double  monster.  Birth  weight,  ,S  lbs.  ,S  oz.  (2,410 
il'f  grams).  Delivered  by  cesarean  section  because  of  dystocia 
le  j caused  by  the  duplication  of  the  shoulders. 

I inal  delivery  was  impossible  because  of  the  size 
' of  the  combined  shoulders.  Figure  4 is  that  of 
another  double  monster  which  by  virtue  of  its 
’^1  smaller  size  occasioned  no  difficulty. 

The  most  important  consideration  is  that  the 
-k  diagnosis  should  be  made  [trior  to  the  onset  of 
'sj  labor.  All  patients  with  a history  of  jtrevious 
malformed  infants,  those  with  [tolyhydramnios, 
those  with  malpresentations,  and  those  with  sus- 


Fig.  4.  Double  monster.  Birth  weight,  4 lbs.  3 oz.  (1,900 
grams).  Acute  polyhydramnios,  with  spontaneous  delivery 
following  labor  induced  by  release  of  most  of  amniotic  fluid. 

pected  twins  should  be  subjected  to  X-ray  ex- 
aminations of  the  abdomen.  In  the  absence  of 
polyhydramnios  the  presence  of  a monster  is 
usually  unsuspected.  If  the  double  monster  is 
not  too  large,  the  patient  may  be  allowed  to  go 
into  labor,  [larticularly  if  the  feet  are  [jresenting. 
If  the  fetuses  are  large,  cesarean  section  may  be 
the  most  appropriate  treatment.  The  patient 
who  develops  obstructive  dystocia  due  to  a mon- 
ster is  freciuently  more  safely  delivered  by  extra- 
peritoneal  cesarean  section  than  by  a destructive 
operation  on  the  fetus.  One  further  jroint  in 
thera[)y  is  to  refute  the  idea  that  labor  should 
be  induced  as  soon  as  the  diagnosis  of  a monster 
or  an  anomalous  infant  has  been  made.^"  \ nor- 
mal onset  of  labor  indicates  that  the  proper  time 


186 


Dystocia  due  to  Fetal  Abnormalities — Barter 


APRII,  1952 


for  delivery  is  at  hand.  Induced  labor  on  the 
contrary  is  unpredictable.  There  is  no  reason  to 
induce  labor  in  the  absence  of  acute  polyhy- 
dramnios. 

Polyhydramnios 

Polyhydramnios  occurs  frequently  in  the  [ires- 
ence  of  fetal  anomalies.  The  accompanying  ex- 
cessive fluid  may  be  more  of  a problem  than  is 
the  abnormal  fetus.  Acute  polyhydramnios  oc- 
curs only  rarely. ^ When  present  it  may  con- 
stitute an  obstetrical  emergency.  The  painful 
distention  of  acute  polyhydramnios  may  be  con- 
fused with  premature  separation  of  the  placenta. 
If  the  patient  is  having  respiratory  and  cardiac 
embarrassment,  the  excessive  amniotic  fluid  must 
be  released  from  the  confining  membranes.  This 
can  be  accomplished  by  means  of  a trocar  or  a 
spinal  needle  piercing  the  membranes  through 
the  cervix.  The  most  important  point  is  that  the 
fluid  must  be  released  slowly.  One  of  the  real 
dangers  from  a sudden  decrease  in  intrauterine 
capacity  is  separation  of  the  placenta.  The  re- 
lease of  several  liters  of  fluid  should  require  at 
least  an  hour.  If  the  membranes  are  lacerated 
with  a hook,  instead  of  carefully  punctured,  the 
loss  of  fluid  may  be  entirely  too  rapid.  In  this 
series  abdominal  aspiration  of  the  amniotic  fluid 
has  not  been  attempted,  although  such  aspiration 
has  been  recommended  from  time  to  time.- 

When  dealing  with  either  chronic  or  acute 
hydramnios  an  X-ray  film  of  the  abdomen  may 
not  be  conclusive  because  of  the  excessive  fluid. 
If  the  films  are  inconclusive,  a good  practical 
idea  is  to  repeat  the  film  after  the  fluid  has  been 
released.  In  that  way  definite  shadows  may  be- 
come readily  apparent.  The  further  management 
of  the  patient  may  be  greatly  simplified  by  virtue 
of  the  new  information  thus  gained. 

Summary 

1.  Dystocia  due  to  abnormalities  of  the  fetus 
occurs  infrequently. 

2.  The  most  serious  type  of  dystocia  with  a 


fetus  of  excessive  size  is  concerned  with  the  de- 
livery of  the  shoulders. 

3.  When  shoulder  dystocia  does  occur,  the 
fetal  mortality  is  excessive,  disabling  birth  in- 
juries are  common,  and  the  maternal  morbidity 
is  markedly  increased. 

4.  The  best  method  of  treatment  for  shoulder 
dystocia  is  its  prevention.  Cesarean  section  may 
be  indicated  solely  on  the  basis  of  excessive  fetal 
size. 

5.  Anomalies  of  the  central  nervous  system  are 
the  most  common  defect  in  malformed  fetuses. 

6.  With  single  monsters,  hydrocephaly  is  the 
greatest  source  of  dystocia. 

7.  After  decompression  of  the  head  hydro- 
cephalic fetuses  may  be  delivered  through  the 
birth  canal  without  hazard  to  the  mother. 

8.  Double  monsters  may  cause  serious  dys- 
tocia by  nature  of  their  size,  by  their  multi- 
plicity of  parts,  and  by  their  increased  body  mass. 

9.  Polyhydramnios  is  frecjuently  found  with 
anomalous  infants. 

10.  Acute  polyhydramnios,  by  its  effect  on 
the  cardiac  and  respiratory  system  of  the  mother, 
may  recpiire  immediate  release  of  the  excessive 
amniotic  fluid. 

1 1 . Separation  of  the  placenta  may  occur  if 
the  fluid  is  released  too  rapidly  when  hydram- 
nios of  a marked  degree  is  present. 

12.  Repeat  X-ray  examinations  after  the  re- 
lease of  the  excessive  fluid  in  polyhydramnios 
may  be  necessary  to  discover  an  anomalous  fetus. 

BIBLIOGRAPHY 

1.  Irving,  F.  C.:  Outline  of  .Xhnornial  Obstetrics,  rev.  ed. 

Boston:  Mahady,  1944,  pp.  191-205. 

2.  Rivf.tt,  L.  C.:  .\ni.  J.  Ohst.  & Gynec.,  1946,  52,  890. 

5.  .Miller,  H.  C.:  J.  Pediat.,  1946,  29,  455. 

4.  Koff,  .\.  K.,  .VXD  PoTTF.R,  E.  L. : .\m.  J.  .\bst.  &:  Gynec., 

1959,  38,  412. 

5.  B.\rnl’M,  C.  G.:  Ibid.,  1945,  50,  459. 

6.  X.ATH.VNSON,  J.  X.:  Ibid.,  1950,  60,  54. 

7.  (f.VLKiNS,  L.  A.:  Ibid.,  1948,  56,  167. 

8.  Gref.nhill,  j.  P.:  Principles  and  Practice  of  Obstetrics, 

originally  by  J.  B.  DeLee,  10th  cd.  Philadelphia: 

launders,  1951,  chap.  40. 

{Continued  on  page  23S) 


THE  MANAGEMENT  OE  ABNORMAL  AND  EXCES- 
SIVE UTERINE  BLEEDING 


C ^ / ARTICLES  appear  regularly  ad- 
vising the  use  of  sex  hormones  for  treating  the 
condition  called  “functional  uterine  bleeding.” 
Estrogen,  progesterone,  gonadotropin  and  testos- 
terone, alone  or  in  various  combinations,  have 
their  proponents  in  managing  abnormal  men- 
strual bleeding.  It  is  unfortunate  that  such  reports 
put  the  emphasis  upon  treatment  of  a symptom, 
abnormal  bleeding,  rather  than  upon  the  im- 
portance of  arriving  at  a diagnosis.  The  term 
“functional  bleeding”  is  not  diagnostic,  nor  is 
it  easy  to  define.  As  generally  used  it  pertains  to 
individuals  manifesting  abnormal  bleeding  in 
whom  no  obvious  cause  for  the  bleeding  can  be 
found.  This  report  concerns  the  management  of 
336  women  complaining  of  abnoimal  and  exces- 
sive uterine  bleeding,  not  associated  with  preg- 
nancy, in  whom  pelvic  examination  failed  to 
demonstrate  any  gross  cause  for  the  bleeding. 
It  includes  postmenopausal  bleeding  of  any  de- 
gree, intermenstrual  bleeding  that  persists  for 
2 cycles  or  longer,  and  menometrorrhagia  lasting 
longer  than  3 months.  All  women  in  this  group 
were  subjected  to  diagnostic  curettage  with  tis- 
sue report  before  any  further  attempt  was  made 
to  classify  or  treat  them  and  to  biopsy  examina- 
tion of  the  cervix  unless  a healthy,  unbroken 
mucosa  was  everywhere  visible. 

Accurate  records  of  the  exact  occasion,  fre- 
cjuency,  and  degree  of  bleeding  are  important 
in  making  a diagnosis.  Women  who  are  dubious 
about  this  and  who  will  not  keep  a written  record 
are  not  to  be  trusted.  They  may  be  falsifying  for 
purposes  of  attention-seeking  or  for  desire  to 
have  a hysterectomy  for  contraceptive  purposes. 
Written  records  for  the  doctor  are  im{)ortant  too. 
Some  women  bleed  excessively  when  they  are 


ROLAND  BIEREN,  M.D.,  E.A.C.S. 

Gynecologist,  Group  Health  Association,  Washington 


under  stress,  and  if  this  has  been  previously  noted 
in  the  record  it  helps  one  to  arrive  at  a diagnosis. 
Steady  progression  toward  more  and  longer 
bleeding  is  significant.  When  the  record  shows 
lessening  of  the  flow  and  shortening  of  the  periods 
there  need  not  be  any  concern,  provided  there 
is  not  some  constitutional  disorder  present,  such 
as  hyperthyroidism.  Secondary  oligo-amenor- 
rhea  is  occasionally  seen  in  perfectly  healthy, 
normal  women  and  per  se  is  no  reason  for  con- 
cern or  for  hormone  treatment. 

Perhaps  the  most  difficult  feature  to  determine 
in  this  group  is  the  degree  of  severity  of  the  bleed- 
ing. For  purposes  of  convenience  for  the  record 
each  individual  included  in  the  study  is  classed 
under  1 of  4 groups  as  indicated  in  table  1. 

TABLE  1 
Degree  of  Severity 

Grouj)  1.  Postmeno[)ausal  bleeding  in  any  degree. 

Grou])  2.  Intermenstrual  bleeding,  occasional  s[)otty  to  con- 
tinuous and  scanty. 

Group  3.  Menorrhagia  moderate,  not  exceeding  4 days, 
with  soaking  of  double  pad  in  1 to  3 hours. 

Group  4.  Menometrorrhagia,  severe,  uncontrollable  for  6 
hours  or  longer  in  that  the  woman  is  unable  to  leave  the 
house  because  she  will  dri])  through  a double  [rad  in  less 
than  30  minutes,  stains  her  clothes,  floor  and  bedclothes 
and  will  have  a gush  of  blood  and  clots  when  she  strains 
at  toilet.  .Any  instance  of  excess  bleeding  persisting 
beyond  4 days  or  producing  distinct  secondary  anemia. 


In  all,  24  women  fall  into  the  severe  group  4, 
44  in  the  postmenopausal  group  1 , and  the  re- 
maining 268  about  ecpially  distributed  in  groups 
2 and  3.  Women  in  all  4 groups  are  advised  to 
have  a diagnostic  curettage  done  promf)tly.  When 
the  woman  delays  this  operation  she  is  told 
bluntly  that  she  is  “playing  Russian  roulette 
with  herself”  and  that  further  delay  will  not  be 


187 


188 


Uterine  Bleeding — Bieren 


APRIL,  1952 


condoned.  Often  a woman  will  object  to  being 
examined  while  she  is  bleeding,  but  if  the  bleed- 
ing continues  week  after  week  there  is  no  alter- 
native and  the  physician  must  be  insistent. 

In  the  group  of  336  women  manifesting  no 
gross  pelvic  pathology  on  vaginal  examination 
there  has  been  a definite  diagnosis  made  in  102 
of  them  of  a condition  pertinent  to  the  bleeding. 
This  is  shown  in  detail  in  table  2. 

TABLE  2 
Diagnosis 


Malignant  neoplasm 10 

Nonmalignant  neoplasm 16 

Senile  vaginitis 38 

Emotional  disturbance 22 

Thyroid  disorder 12 

Purpura 2 

Hypertension 2 


102 


Of  the  26  diagnoses  of  neoplasm,  10  were  made 
by  curettage  and  biopsy  and  16  developed  dur- 
ing periods  of  observ^ation  of  from  1 to  4 years 
following  the  original  examination  and  curettage 
as  shown  in  table  3. 

T.\BLE  3 
Nature  of  Neoplasm 

1.  Discovered  by  curettage  and  biopsy; 


Submucous  myoma 3 

Adenocarcinoma  (corpus) 6 

Squamous  Cancer  (cervix) 1 


10 

2.  Discovered  during  subsequent  observation; 


Fibromyomata 13 

Cancer  of  ovary 3 


16 


The  13  instances  of  fibromyomata  were  chiefly 
interstitial  in  type.  All  were  ultimately  subjected 
to  hysterectomy.  The  3 ovarian  carcinomata 
occurred  in  women  who  were  under  periodic  ob- 
servation because  of  episodes  of  abnormal  bleed- 
ing. In  all  3 the  first  symptom  was  an  uncomfort- 
able abdominal  enlargement,  occurring  in  a few 
weeks.  Diagnosis  was  suspected  when  progressive 


ascites  and  a lower  abdominal  mass  were  found. 
At  laparotomy  they  were  already  in  an  advanced 
stage.  One  adenocarcinoma  of  the  corpus  was 
advanced  when  discovered  because  of  the  pa- 
tient’s delay.  She  had  concealed  her  postmeno- 
pausal bleeding  from  her  family  for  almost  2 
years  before  her  daughter  noticed  that  blood 
stains  were  in  her  mother’s  bedclothes.  The  re- 
mainder of  the  malignant  neoplasms  were  in  an 
early  and  curable  stage  when  the  diagnosis  was 
made.  Four  of  these  women  complained  of  spotty 
intermenstrual  bleeding  persisting  for  2 succes- 
sive cycles.  One  had  postmenopausal  staining  for 
3 weeks.  The  1 remaining  is  presented  as  case 
no.  1.  The  youngest  of  these  6 was  40,  the  oldest 
54,  and  the  average  age  48. 

Illustrative  Cases 

Case  1.  A highly  psychoneurotic  unmarried  woman 
aged  52  who  had  not  had  regular  menses  for  over  10 
years  and  who  had  taken  1 mg.  of  diethylstilbestrol  daily 
for  the  past  10  years  stated  that  about  twice  a year  she 
hafl  had  an  episode  of  bleeding  which  usually  stopped 
within  a week  or  10  days  after  the  drug  was  discontinued. 
On  an  office  visit  she  reported  that  she  had  not  taken 
the  drug  for  4 weeks  and  was  still  bleeding.  Vaginal 
examination  revealed  nothing  noteworthy.  It  was  not 
convenient  for  her  to  enter  the  hospital  at  this  time,  and 
it  was  agreed  to  wait  another  2 weeks.  She  was  given 
intramuscular  testosterone,  25  mg.  3 times  weekly,  to 
relieve  her  hot  flushes  which  had  recurred  to  a very 
annoying  extent.  .At  the  end  of  another  2 weeks  she  was 
still  bleeding  in  moderate  degree  and  consented  to  a 
diagnostic  curettage.  Tissue  obtained  was  scanty  and 
gelatinous  in  consistency.  It  was  reported  as  adeno- 
carcinoma. This  ca.se  is  a good  object  lesson.  When  a 
woman  is  taking  estrogenic  hormone  and  begins  to  have 
excessive  or  prolonged  bleeding  the  estrogen  is  usually 
responsible,  but  not  always  so.  If  bleeding  continues  for 
as  long  as  3 weeks  after  the  drug  has  been  discontinued, 
a diagnostic  curettage  is  in  order. 

Case  2.  The  patient  was  unmarried  and  63  years  old. 
Menopause  had  occurred  at  the  age  of  45.  .At  the  age 
of  56  she  began  to  have  spotty  vaginal  bleeding  and  the 
curetted  tissue  was  reported  as  nonmalignant.  Over 
the  next  6 years  she  continued  to  have  episodes  of  spotty 
bleeding  and  had  a total  of  5 curettages.  One  year  after 
the  last  one  she  was  seen  by  me  and  was  bleeding  again. 
She  was  a tense,  highly  nervous  person  who  was  unable 


VOL.  XXI,  NO.  4 


Medical  Annals  of  the  District  of  Columbia 


189 


to  relax  for  vaginal  examination.  She  was  scheduled  for 
examination  under  an  anesthetic  and  curettage  at  the 
same  time.  At  this  time  there  was  seen  a pronounced 
degree  of  senile  vaginitis.  Tissue  obtained  was  moderate 
in  amount  and  friable.  It  was  reported  as  adenocar- 
cinoma. Final  report  after  hysterectomy  was  that  the 
growth  was  limited  mainly  to  the  endometrium  with 
just  superficial  invasion  of  the  myometrium. 

In  these  336  women  it  has  been  thought  neces- 
sary to  repeat  the  curettage  at  approximately 
yearly  intervals  in  several  instances.  Eleven 
women  have  had  2 each,  and  2 have  had  3 such 
operations,  because  of  continuing  or  recurrent 
episodes  of  abnormal  bleeding.  Although  not 
excessive  they  were  thought  to  be  sufficient  to 
warrant  another  investigation. 

There  is  a type  of  bleeding  associated  with 
ovulation  that  should  be  mentioned,  although 
none  of  the  cases  in  this  study  are  of  such  nature. 
Occasionally  a woman  is  seen  who  has  a record 
of  staining  a little  just  about  midway  between 
menses,  when  ovulation  is  expected.  When  this 
has  been  present  for  some  time  and  has  not  in- 
creased, nothing  more  than  a periodic  examina- 
tion is  warranted.  If  it  is  a recent  development 
in  a woman  35  or  older,  curettage  should  be 
employed  to  make  sure  it  is  nothing  more. 
Another  cause  of  intermenstrual  staining  and 
profuse  periods  is  abnormal  ovulation.  Typically, 
when  this  occurs,  lower  abdominal  pain  develops 
at  the  time  of  ovulation.  Subsequently  spotty 
intermenstrual  bleeding  or  a profuse  and  painful 
period  will  occur,  or  both  the  staining  and  the 
profuse  period  will  be  recorded.  Examination  of 
the  woman  usually  reveals  an  enlarged  and  quite 
tender  ovary.  The  condition  is  commonly  mis- 
diagnosed and  treated  as  “inflammation”  of  the 
ovary.  Actually  it  is  due  to  a hemorrhagic  follicle 
or  corpus  luteum  hemorrhagicum  and  will  sub- 
side spontaneously  with  expectant  treatment.  It 
commonly  occurs  in  women  under  stress  and 
occasionally  after  active  coitus  at  ovulation  time. 
Rarely  the  hemorrhage  into  and  from  the  ovary 
is  of  sufficient  degree  to  necessitate  laparotomy. 

Emotional  factors  undoubtedly  influence  many 
women’s  menses.  The  exact  incidence  of  this  is 


difficult  to  evaluate,  because  any  woman  hav- 
ing a tendency  toward  excessive  bleeding  will 
invariably  have  an  increase  in  flow  when  she  is 
under  stress.  In  this  series  22  women  were  dis- 
covered to  have  emotional  problems  which  ap- 
peared to  influence  directly  their  bleeding.  The 
physician  not  experienced  in  searching  for  emo- 
tional reasons,  or  unwilling  to  do  so,  will  seldom 
find  them.  At  times  they  are  unmistakable.  Such 
an  instance  is  the  woman  with  an  overdue  period 
and  a fear  of  pregnancy.  When  she  is  told  the 
pregnancy  test  is  negative  she  will  commonly 
begin  a profuse  and  prolonged  period.  Another 
common  cause  is  the  auto  accident,  which  often 
evokes  a premature,  profuse  and  prolonged  pe- 
riod. Women  unable  to  conceive  who  are  put 
under  pressure  by  their  husbands  and  relatives 
will  sometimes  complain  that  they  are  having  a 
“hemorrhage”  with  each  period.  They  are  so  cer- 
tain they  have  become  pregnant  each  month  that 
they  try  to  convince  everyone  that  they  are  hav- 
ing a miscarriage.  Examination  in  such  instances 
will  usually  show  the  amount  of  bleeding  to  be 
surprisingly  small  in  comparison  with  the  degree 
of  complaint.  On  the  other  hand,  it  is  amazing 
how  long  some  can  bleed  excessively  without 
their  activities  being  greatly  affected.  The  next 
2 case  reports  show  unquestionable  emotional 
factors  that  superficially  might  not  be  evident. 

Illustrative  Cases 

Case  3.  Since  the  menarche  at  14  this  unmarried 
woman  of  26  years  has  had  regular  spotty  bleeding 
between  periods.  .At  the  age  of  24  she  was  hospitalized 
for  6 weeks  for  study  with  curettage,  but  nothing  ab- 
normal could  be  found.  Two  years  later  she  was  first 
referred  for  gynecologic  consultation  in  this  series  after 
a complete  diagnostic  work-up,  which,  as  before,  had 
shown  nothing  organically  wrong  with  her.  She  was 
advised  not  to  worry  about  the  bleeding  and  to  return 
for  reexamination  every  6 months.  If  the  bleeding  in- 
creased appreciably  she  was  to  return  sooner.  .At  this 
time  she  volunteered  the  information  that  overwork, 
worry  and  emotional  upset  would  aggravate  the  bleeding 
temporarily.  .A  year  later  she  stated  her  intention  of 
getting  married  in  the  near  future  and  was  fitted  with  a 
diaphragm  at  her  request.  Several  months  later  she 
returned  complaining  that  she  had  been  bleeding  con- 


190 


Uteri ne  El eedi ng — B ieren 


APRIL,  1952 


stantly  for  over  2 months.  The  use  of  testosterone 
intramuscularly,  25  mg.  every  other  day  for  6 doses,  had 
no  effect  upon  the  bleeding.  .A  curettage  was  performed 
with  the  tissue  reported  as  proliferative  endometrium. 
The  uterus,  tubes  and  ovaries  were  always  normal  on 
examination.  During  the  hospital  stay  she  volunteered 
some  interesting  information.  Her  intermenstrual  bleed- 
ing had  begun  just  after  her  menarche  with  an  emotional 
disturbance.  Confined  to  bed  for  some  illness,  she  had 
listened  to  her  mother’s  distress  in  labor  with  an  un- 
wanted pregnancy  in  the  next  room  with  paper-thin 
walls.  They  were  poverty-stricken  at  the  time,  and  the 
mother,  with  little  medical  attendance  and  no  analgesia, 
suffererl  a difficult  and  painful  2-day  labor.  As  she  re- 
counted the  experience  many  years  later,  it  was  obvious 
that  it  was  still  almost  unbearable  for  her  to  think  about. 
It  is  even  more  significant  that  her  bleeding  became  con- 
tinuous after  she  and  her  husband  decided  to  have  a 
child.  After  she  stopped  using  her  diaphragm  the  bleeding 
would  not  stop.  Since  she  was  bleeding  she  could  not  have 
sex  relations  and  therefore  could  not  become  pregnant. 

Case  4.  The  patient  was  married,  29  years  old,  and 
had  3 children  aged  7,  5 and  3.  Five  months  previously 
while  living  abroad,  her  husband  was  unexpectedly 
transferred  back  to  this  country,  leaving  her  to  follow 
with  3 children  and  the  household  goods,  and  without 
help.  After  arriving  she  moved  again  3 times  in  as  many 
months,  each  time  to  a different  part  of  the  country. 
At  the  beginning  of  this  trek  she  began  a menstrual 
period  and  just  never  stopped  bleeding.  In  4 months 
she  had  consulted  4 different  physicians,  each  of  whom 
gave  her  hormone  injections.  She  arri\ed  in  Washington 
exhausted  and  nearly  frantic  about  the  bleeding.  She  was 
hospitalized  and  a curettage  performed.  The  tissue  was 
reported  as  benign  secretory  endometrium.  Review  of  her 
earlier  medical  record  from  former  residence  here  re- 
vealed the  fact  that  she  had  once  before  evidenced  a 
tendency  to  bleed  excessively  when  under  stress.  She  was 
reassured  that  if  she  rested  uj)  and  recovered  from  her 
strenous  travel  ordeal  no  further  treatment  would  in  all 
likelihood  be  necessary.  In  any  event  there  was  nothing 
to  be  concernefl  about  other  than  the  annoyance  of 
having  to  menstruate  overly  long.  .\  day  or  so  later  the 
bleeding  ceased,  and  several  months  have  elapsed  with 
entirely  normal  menses. 

Twelve  women  in  this  study  manifested  some 
degree  of  thyroid  disorder.  Two  had  my.xedema. 
Seven  had  no  symptoms  e.xeept  profuse,  pro- 
longed menses.  The  BMR  was  normal  in  all  7. 
On  a grain  of  thyroid  e.xtract  daily  their  menses 
reverted  to  a normal  cycle.  'Fhree  women  had 


hyperthyroidism  and  developed  excess  bleeding 
when  treated  with  propylthiouracil.  Stopping  the 
use  of  the  drug  relieved  the  bleeding  in  2.  The 
other  is  reported  as  case  5. 

Illustrative  Case 

Case  5.  The  patient  , was  married,  41  years  old,  and 
had  2 children  aged  14  and  11.  After  3 weeks’  treatment 
with  propylthiouracil  she  began  a menstrual  period  which 
would  not  stop,  even  after  the  drug  was  discontinued. 
After  7 weeks  of  bleeding  her  hemoglobin  fell  to  42 
per  cent,  and  it  was  necessary  to  give  a transfusion. 
Her  thyroid  dysfunction  stabilized  well,  but  she  con- 
tinued to  have  prolonged  and  excessive  periods.  Intra- 
muscular testosterone,  75  mg.  a week,  had  no  effect  upon 
the  bleeding.  She  was  ultimately  relieved  by  a hyster- 
ectomy. 

Thirty-eight  of  44  women  complaining  of  post- 
menopausal bleeding  were  found  to  have  senile 
vaginitis  in  sufficient  degree  to  be  responsible  for 
the  bleeding.  All  responded  promptly  to  local 
vaginal  estrogen  therapy.^  Three  had  adenocar- 
cinoma of  the  corpus  as  shown  elsewhere  in  this 
article.  Two  women  in  this  postmenopausal 
group  have  had  intermittent  spotty  bleeding 
from  a healthy-appearing  cervical  stump,  left 
from  previous  subtotal  hysterectomy.  In  both  the 
remaining  cervical  canal  has  been  e.xplored  care- 
fully with  a sharp  curet  under  anesthesia  but  no 
tissue  obtained.  One  woman  aged  69  at  present 
had  both  radium  and  X-ray  treatments  in  her 
early  forties  for  severe  menorrhagia.  Since  then 
she  has  had  about  4 to  5 menstrual-like  periods 
of  bleeding  a year.  Curettage  on  2 occasions  has 
failed  to  produce  any  tissue  from  a tiny,  senile 
uterus.  She  is  tremendously  obese,  has  an  en- 
larged heart,  and  her  systolic  blood  pressure  is 
well  over  200.  1 believe  there  may  be  a connec-  j 
tion  between  the  hypertension  and  the  bleeding 
episodes,  which  are  definitely  from  the  uterus 
and  not  from  the  vagina.  One  other  woman  in 
the  study  has  a systolic  pressure  that  averages 
220,  and  I think  it  has  a relation  to  her  excessive 
menses. 

Other  etiologic  factors  exist.  Two  women  in 
the  study  have  definite  thrombocytopenic  pur- 


VOI.  XXI,  NO.  4 


Medical  Annals  of  the  District  of  Columbia 


191 


pura.  Both  manifest  excessive  menses  and  epi- 
sodes of  intermenstriial  staining  from  time  to 
time.  These  2 are  the  only  exceptions  to  the  rigid 
rule  of  curettage  in  these  cases.  As  long  as  their 
pelvic  findings  remain  normal  on  examination 
the  medical  department  has  ruled  out  any  sur- 
gery. Both  are  kept  under  close  supervision.  In- 
flammatory disease  of  the  pelvis,  both  Neisserian 
and  acid-fast  is  often  reported  elsewhere  as  a 
cause  of  excessive  and  abnormal  bleeding.  The 
former  is  rarely  seen  in  this  organization.  In  a 
4-year  period  3 patients  were  thought  to  have 
tuberculous  salpingitis.  All  3 responded  so  well 
to  rest  and  streptomycin  that  surgical  confirma- 
tion was  not  necessary.  None  of  the  3 exhibited 
abnormal  menses. 

After  excluding  the  individuals  with  definite 
diagnosis  we  have  left  a group  of  women  for 
whom  we  have  yet  no  explanation  of  the  mecha- 
nism of  the  excess  and  abnormal  bleeding.  It  is 
easy  to  slip  on  this  group  the  label  of  “functional 
bleeding,’’  “hyperplasia,”  or  “irregular  shedding 
of  the  endometrium,”  as  is  often  suggested.  Path- 
ologic tissue  reports  of  phases  of  the  endometrium 
including  both  cystic  and  so-called  atypical  hy- 
perplasia have  had  no  bearing  on  the  clinical 
management  of  this  group,  either  in  checking 
the  bleeding  or  in  indicating  any  certain  individ- 
uals likely  to  develop  true  neoplasm  in  the  future. 
Until  our  knowledge  is  much  better  than  it  is 
at  present  we  must  regard  all  such  women  as 
possible  candidates  for  future  neoplasm  and  use 
periodic  examinations,  with  curettage  when  in- 
dicated, as  the  mechanism  for  early  diagnosis. 

. Furthermore,  each  wonian  usually  proves  to  be 
a particular  problem  that  does  not  lend  itself 
readily  to  classification  or  management  in  a rou- 
tine that  has  fixed  and  rigid  rules.  A typical 
person  of  this  kind  is  between  35  and  45  years 
of  age,  has  had  1 or  more  pregnancies,  and  has 
manifested  a definite  increase  in  bleeding  which 
, has  persisted  6 months  or  longer.  Pelvic  exami- 
I nation  has  failed  to  reveal  any  gross  lesions. 

I Tissue  obtained  by  curettage  has  been  reported 
I negative  for  cancer.  What  should  be  clone  next? 

i 

I 

I 


1 

i 


Experience  with  this  grouf)  has  shown  that  pa- 
tients with  a mild  to  moderate  degree  of  bleed- 
ing, groups  2 and  3,  table  1,  can  be  managed 
with  periodic  observation  and  the  assurance  that 
nothing  serious  will  come  of  the  bleeding  except 
the  inconvenience  it  occasions.  Natural  meno- 
pause will  ultimately  sto[)  it  spontaneously. 
Spontaneous  remission  will  often  occur  without 
any  treatment  and  sometimes  follows  the  curette- 
ment.  Even  though  at  times  the  blood  loss  ap- 
pears to  be  great,  experience  has  shown  that  it 
seldom  affects  the  blood  count  unless  it  is  pro- 
longed over  many  weeks.  When  decided  second- 
ary anemia  is  caused  by  the  bleeding,  the 
woman  should  be  included  in  group  4,  which 
includes  patients  with  severe  bleeding.  Women 
with  a known  tendency  to  anemia  must  .be 
watched  carefully  and  have  frecjuent  blood 
counts  made.  Women  with  persistent  severe 
bleeding,  group  4,  table  1,  will  reejuire  radical 
measures  unless,  providentially,  as  sometimes 
happens,  natural  menopause  intervenes.  Of  the 
original  group  of  336,  no  definite  etiology  was 
found  in  234  women  for  the  bleeding.  Of  this 
latter  group  exactly3  2 have  fallen  in  the  severe 
bleeding  group,  and  the  bleeding  has  been  ter- 
minated as  shown  in  table  4. 

T.-\BLE  4 
Type  of  Termination 


Hysterectomy 5 

Radium  jilus  hysterectomy 2 

Radium  therapy 12 

Deep  X-ray  therapy 4 


23 


At  no  point  in  this  study  and  in  not  a single 
individual  case  has  there  been  any  definite  or 
logical  indication  for  the  use  of  sex  hormones, 
with  the  one  exception  of  estrogen  locally  for 
senile  vaginitis.  With  rare  exception  the  use  of 
oral  or  intramuscular  estrogen  is  not  indicated  in 
postmenojiausal  women.  Many  women  in  the 
three  premenojiausal  grotqis  with  abnormal 
bleeding  will  insist  on  something  “more”  short  of 


192 


Uterine  Bleeding — Bicren 


APRIL,  1952 


radical  measures.  As  a placebo  they  may  be 
treated  with  oral,  sublingual  or  intramuscular 
hormones.  Such  therapy  has  yet  to  be  proved  to 
be  more  than  on  a trial  and  error  basis.  If  one  does 
not  work  another  may  be  tried,  or  a combination 
of  2 or  3.  Diethylstilbestrol,-  hexestroP  and  other 
estrogens  in  various  types  and  dosage,  together 
or  separately  with  progesterone  and  testosterone, 
have  been  very  disappointing  in  this  respect. 
Estrogen  often  increases  the  bleeding.  The  ap- 
parent occasional  success  with  hormones  does 
not  occur  any  more  frequently  than  does  spon- 
taneous remission  in  women  not  taking  them. 
Tremendously  excessive  doses  of  stilbestrol  not 
only  violate  sound  physiologic  and  pharmacologic 
principles  but  can  produce  violent  bleeding  when 
discontinued.  On  occasions  testosterone,  in  doses 
up  to  75  mg.  weekly  sublingually  or  intramus- 
cularly, seems  helpful.  However,  when  help  is 
needed  badly,  as  in  the  next  3 cases  presented, 
it  appears  to  have  little,  if  any,  effect  on  the 
bleeding. 

Illustrative  Cases 

Case  6.  The  patient  was  a married  woman  of  37  with 
3 children  aged  7,  5 and  3.  For  5 months  she  had  noticed 
intermenstrual  bleeding  which  had  increased  with  each 
cycle.  diagnostic  curettage  and  biopsy  of  the  cervdx 
were  performed,  with  tissue  reported  benign,  .\fter  this 
the  bleeding  stopped  for  3 weeks;  then  a period  began 
and  bleeding  continued  over  the  next  6 weeks,  becoming 
more  severe  each  week.  She  was  readmitted  to  the 
hospital  with  a hemoglobin  of  50  per  cent.  Treatment 
was  the  use  of  intramuscular  testosterone,  25  mg.  daily, 
for  the  next  7 days  and  transfusions  as  indicated.  By  the 
end  of  a week  it  had  become  necessary  to  administer 
500  c.c.  of  whole  blood  daily  just  to  keep  up  with  blood 
loss,  and  a total  hysterectomy  was  performed  in  order 
to  check  the  bleeding.  The  uterus  was  found  to  be  normal, 
grossly  and  microscopically. 

Case  7.  married  woman  of  39  with  1 child  aged  14 
complained  of  4 successive  menstrual  periods  during 
which  she  flooded,  twice  excessively.  curettage  was 
performed,  and  the  tissue  was  reported  benign.  The 
next  3 menses  were  normal,  .\fter  these  she  was  hos- 
pitalized with  a spinal  injury  resulting  from  a bad  fall. 
In  the  first  week  she  had  an  emergency  operation  for 
intestinal  obstruction  produced  by  a volvulus.  Her 


conv'alescence  was  then  further  complicated  by  an  in- 
fection of  the  abdominal  incision  resulting  in  a large 
abscess  which  had  to  be  drained  surgically.  Just  after 
the  spinal  injury  she  began  to  bleed  moderately  and 
never  entirely  stopped.  Intramuscular  administration  of 
testosterone,  100  mg.  weekly  for  4 weeks,  had  no  notice- 
able effect  on  the  bleeding.  After  5 weeks  in  the  hospital 
she  was  sent  home  for  further  convalescence.  At  this 
time  she  was  weak,  looked  washed-out,  and  was  still 
bleeding.  She  was  put  on  ferrous  sulfate,  9 grains  daily, 
and  Vitamin  B-complex,  6 capsules  daily.  The  bleeding 
continued  without  respite  for  another  2 months,  after 
which  she  was  put  back  in  the  hospital  for  transfusion. 
She  was  given  an  intrauterine  radium  treatment  of 
2,000  mg.  hours  of  radium  element.  Three  days  later  her 
bleeding  ceased  and  she  began  to  recover  from  all  the 
misfortune  she  had  suffered.  A year  later,  after  she  had 
fully  recovered  and  was  in  good  condition  for  another 
operation,  she  began  to  bleed  again.  After  this  persisted 
for  3 weeks  a total  hysterectomy  was  performed,  from 
which  a speedy  recovery  was  made. 

Case  8.  .\  married  woman  aged  47,  with  1 child  aged 
17,  was  seen  with  the  complaint  of  progressive  menor- 
rhagia of  6 months’  duration,  the  last  2 menses  being 
severe.  curettage  was  performed,  and  the  tissue  ob- 
tained was  reported  benign.  She  continued  to  have 
excessive  menses  which  were  unaffected  by  the  oral 
administration  of  30  mg.  of  Pranone  daily,  beginning  a 
week  before  a period  was  due  and  continuing  until  it  was 
finished.  Hysterectomy  was  advised,  but  the  patient  was 
unwilling  to  have  the  operation  performed.  She  was  not 
seen  for  4 months  and  was  next  heard  of  when  a physician 
who  had  seen  her  at  home  phoned  requesting  that  she  be 
hospitalized  as  an  emergency.  Four  weeks  before,  she  had 
completed  a course  of  deep  X-ray  treatments  to  her 
ovaries,  .-\fter  this  she  bled  continuously  and  excessively 
and  became  very  weak.  On  admission  her  hemoglobin 
was  approximately  30  per  cent.  Repeated  transfusions  of 
whole  blood  were  administered  until  the  bleeding  sub- 
sided and  her  blood  picture  stabilized,  approximately 
3 weeks.  The  first  week  in  the  hospital  she  was  given  50 
mg.  of  intramuscular  testosterone  daily  with  no  ap- 
parent effect  on  the  bleeding.  She  dev'eloped  a slight 
huskiness  of  the  voice  and  a few  months  later  showed  a 
slight  but  definite  growth  of  coarse  hair  on  her  face. 

This  last  patient  is  the  only  one  in  the  study 
in  whom  the  use  of  testosterone  caused  mas- 
culinization;  however,  the  dose  was  excessive. 
If  a maximum  of  75  mg.  weekly  is  adhered  to 
and  not  administered  more  than  2 weeks  in  suc- 
cession, there  should  be  little  danger  of  this.  It 


VOL.  XXI,  NO.  4 


Medical  Annals  of  the  District  of  Columbia 


193 


is  a good  rule  always  to  inform  the  patient  be- 
fore treatment  that  it  is  the  male  sex  hormone 
and  that  prolonged  or  excessive  doses  can  result 
in  masculinization.  It  should  not  be  used  in 
women  with  any  degree  of  acne,  since  even  in 
small  doses  the  skin  condition  will  become  worse. 
Several  instances  of  mild  degrees  of  hirsutism 
have  been  seen  in  dark  brunettes  treated  over 
several  months  with  sublingual  metandren  for 
dysmenorrhea.  This  tendency  does  not  appear 
to  be  as  pronounced  in  blondes.  The  physician 
had  best  remember  that  increase  in  hair  scarcely 
perceptible  to  him  may  be  considered  quite  a 
blemish  by  the  woman. 

The  controversy  of  radiation  versus  surgery 
in  managing  the  severe  types  of  bleeding  need 
not  be  discussed  in  great  detail.  Each  has  its 
adherents,  and  each  has  advantages  and  dis- 
advantages. In  the  poor  surgical  risk  radiation 
is  usually  preferable.  For  a busy  working  woman 
who  does  not  want  to  take  several  weeks  out  of 
her  schedule  it  is  the  most  convenient.  In  non- 
obese  patients  who  are  good  surgical  risks  and  in 
all  younger  women  for  whom  preservation  of  the 
ovaries  is  desired  elective  total  hysterectomy  is 
the  usual  treatment  of  choice.  Both  surgery  and 
radiation  are  radical  measures,  and  we  must  be 
certain  that  their  use  is  justified.  The  indication 
is  the  degree  of  inconvenience  the  excess  menses 
cause  the  woman."*  We  must  be  careful  not  to 
allow  the  woman  or  the  physician  to  exaggerate 
this  inconvenience. 

Since  the  final  result  of  irradiation  on  normal 
tissue  is  not  clearly  known,  women  so  treated 
must  be  followed  at  intervals  for  the  remainder 
of  their  lives,  ft  is  the  duty  of  the  physician  to 
impress  them  with  the  importance  of  this.  Oc- 
casionally X-ray  treatment  appears  to  aggra- 
vate the  bleeding  as  was  seen  in  case  8.  The  inci- 
dence of  constrictive  senile  vaginitis  appears 
more  common  following  X-ray  therapy.*  This 
increase  is  explainable  by  the  fact  that  the  vag- 
inal vault  is  within  the  “target”  area  and  may 
receive  maximum  exposure  to  the  rays.  Neither 
of  these  disadvantages  appears  to  be  true  for 


intrauterine  radium  administration  in  doses  not 
exceeding  2,000  mg.  hours.  Neither  form  should 
be  used  until  a negative  tissue  report  for  cancer 
has  been  obtained  by  diagnostic  curettage.  The 
use  of  radiation,  particularly  intrauterine  ra- 
dium, without  this  protection  has  been  re- 
peatedly shown  to  mask  symptoms  of  an  already 
present  malignant  growth.  After  radiation  some 
women  continue  to  stain  a little  at  the  time  a 
period  is  due.  If  it  is  no  more  than  this,  nothing 
need  be  done  other  than  periodic  examinations. 
Occasionally  moderate  to  severe  bleeding  begins 
again,  as  reported  in  case  7.  In  such  an  instance 
surgery  is  preferable  to  further  radiation,  unless 
the  patient  is  a very  bad  risk.  Finally,  no  physi- 
cian should  ever  use  deep  X-ray  or  radium  ther- 
apy unless  he  has  had  sound  and  adeejuate  train- 
ing and  experience  in  the  principles  of  radiation 
and  the  indications  for  treatment.  Any  i)hysician 
who  violates  this  rule  is  not  acting  in  the  interest 
of  the  patient  or  of  himself,  and  when  he  does, 
irreparable  damage  to  someone  will  result  sooner 
or  later. 

Summary 

1.  In  this  group  of  336  women  complaining 
of  abnormal  and  excessive  uterine  bleeding  and 
not  manifesting  any  diagnostic  findings  on  vag- 
inal examination,  further  study  resulted  in  a 
diagnosis  pertinent  to  the  management  of  their 
individual  problems  in  102  instances,  10  of  which 
concerned  malignant  neoplasms. 

2.  The  single  most  important  diagnostic  pro- 
cedure is  the  exclusion  of  malignancy  by  olitain- 
ing  tissue  study  through  the  use  of  curettage 
and  biopsy. 

3.  Sex  hormones  have  been  of  little,  if  any, 
value  in  therapy  in  this  group  with  the  single 
exception  of  local  use  of  estrogen  for  senile  vag- 
initis. 

4. ' Hysterectomy,  or  irradiation,  or  both,  has 
been  required  to  control  the  bleeding  in  37  in- 
dividuals (11  per  cent). 

{Conlinued  on  page  238) 


THE  PATHOLOGIC  ANATOMY  OF  DEGENERATIVE 
SHOULDER  LESIONS 

JULIUS  S.  NEVIASER,  M.D.,  E.A.C.S. 

Assistant  Clinical  Professor  of  Orthopedic  Surgery,  George  Wash- 
ington University  School  of  Medicine 


C N RECENT  years  our  concept  con- 

cerning the  nontraumatic  i)ainful  shoulder  has 
undergone  an  “about  face.”  In  1934  Codman^ 
focused  our  attention  on  the  fact  that  changes 
found  in  the  subacromial  bursa  in  cases  of  pain- 
ful shoulder  were  secondary  changes.  Subsequent 
investigators  proved  conclusively  that  the  onus 
of  blame  should  be  placed  on  the  musculotendi- 
nous cuff  and  capsule  as  the  etiologic  agent  in 
the  ])ainful  shoulder. 

The  stability  of  the  shoulder  is  maintained 
primarily  by  soft  tissue  structures.  The  most 
important  structure  is  the  articular  capsule, 
which  completely  envelops  the  shoulder  joint. 
It  is  remarkably  loose,  and  this  accounts  for 
much  of  the  free  movement  of  the  joint  in  all 
directions.  The  capsule  is  prolonged  downward 
in  the  form  of  a fold  in  the  ordinary  dependent 
position  of  the  arm.  When  the  arm  is  abducted 
this  fold  becomes  obliterated  and  the  capsule 
tense.  Synovial  membrane  lines  the  fibrous  layer 
of  the  capsule.  It  extends  from  the  margins  of 
the  glenoid  cavity  over  the  inner  side  of  the 
capsule  and  covers  the  lower  part  and  sides  of 
the  anatomic  neck  of  the  humerus,  where  it  is 
reflected  toward  the  margin  of  the  articular  car- 
tilage of  the  humeral  head.  It  is  important  to 
remember  that  the  inferior  aspect  of  the  humeral 
head  has  the  most  extensive  clothing  of  synovial 
membrane.  On  all  aspects,  exce])t  the  inferior, 
the  capsular  ligament  is  supported  by  muscles, 
the  tendons  of  which  are  more  or  less  intimately 
connected  with  it.  This  intimate  union  of  the 
tendons  of  the  supraspinatus,  infraspinatus,  teres 
minor,  and  subscapularis  converts  them  into  sup- 
porting ligaments  of  the  joint.  The  entire  en- 
veloping structure  is  generally  called  the  cap- 


sulotendinous  or  musculotendinous  cuff  of  the 
shoulder. 

Withers^  demonstrated  that  in  the  adult  the 
capsule  is  fused  with  the  overlying  short  rotator 
muscle.  In  infants  the  short  rotator  muscles  are 
deflnitely  separated  from  the  underlying  capsule 
by  loose  areolar  tissue.  Another  interesting  dif- 
ferential anatomic  flnding  in  infants  is  the  length 
of  the  muscle  fibers  of  the  short  rotator  muscles, 
which  extend  nearly  to  their  insertions  in  the 
tuberosities  of  the  humerus,  whereas  the  findings 
in  adult  are  cpiite  different.  The  tendinous  por- 
tion of  the  muscle  is  much  greater  and  in  some 
instances  extends  medially  to  the  suprascapular 
notch.  It  might  also  be  mentioned  that  these 
findings  are  more  evident  in  the  superior  portion 
of  the  cuff. 

These  heretofore  rarely  mentioned  anatomic 
facts  may  shed  some  light  on  the  degenerative 
])rocesses  that  are  seen  in  relatively  young  adult 
shoulders.  It  is  common  knowledge  among  sur- 
geons who  have  occasion  to  investigate  shoulder 
lesions  that  the  cuff  tissues  are  thickened,  show 
increased  vascularity,  and  no  obvious  demarca- 
tion of  the  tendons  making  up  the  cuff.  No  ad- 
hesions are  noted  between  the  walls  of  the  sub- 
acromial bursa.  iSIicroscopic  examination  of  the 
sections  of  the  capsule  reveal  chronic  inflamma- 
tion with  associated  fibrosis  and  perivascular 
round-cell  infiltration.  Slides  of  the  supraspina- 
tus tendon  reveal  focal  necrosis  with  increased 
vascularity  from  the  periphery  inward.  Asso- 
ciated with  degeneration  is  the  deposition  of 
amorphous  calcium  (calcium  phosphate  and  cal- 
cium carbonate).  This  may  occur  in  tendons, 
ligaments,  aponeurosis,  and  capsular  attach- 
ments as  well  as  in  the  walls  of  the  blood  vessel. 


194 


VOL.  XXI,  NO.  4 


Medical  Annals  of  the  District  of  Columbia 


195 


In  the  region  of  the  shoulder  joint  the  deposition 
is  in  the  tendinous  part  of  the  rotator  cuff  and 
usually  near  the  insertion  of  the  supraspinatus 
at  the  greater  tuberosity  of  the  humerus. 

The  most  common  degenerative  lesion  in  the 
shoulder  is  a calcific  deposit  in  the  rotator  cuff. 
The  clinical  picture  in  the  acute  phase  is  dom- 
inated by  severe  pain.  The  pain  may  be  localized 
to  the  shoulder  joint  or  it  may  be  referred  to  the 
insertion  of  the  deltoid  or  to  the  elbow  and  on 
rare  occasions  to  the  wrist.  It  usually  increases 
in  severity  for  the  first  4 or  5 days  and  then  may 
gradually  diminish.  The  pain  is  of  such  intensity 
that  sleep  is  impossible  and  relief  is  only  obtained 
with  adequate  opiate  sedation.  Accompanying 
the  pain  is  limitation  of  arm  motion,  specifically 
in  the  arcs  of  abduction  and  external  rota- 
tion. 

The  clinical  picture  is  a reflector  of  pathologic 
process.  In  the  acute  phase  surgical  intervention 
may  reveal  the  calcification  to  have  a consistency 
similar  to  that  of  toothpaste.  In  cases  in  which 
the  bursa  is  secondarily  inflamed  the  deposit  is 
milky  and  the  bursa  is  under  great  tension.  The 
floor  of  the  bursa  and  the  superior  surface  of 
the  cuff  are  so  intimately  related  that  any  dis- 
ease of  the  tendon  structure  inevitably  involves 
the  bursa  to  produce  a condition  of  bursitis.  As 
Withers^  so  aptly  stated,  “The  subdeltoid  bursa 
is  the  peritoneum  of  the  spinati  tendons;  like 
1 the  peritoneum  It  shares  the  pathology  of  the 
organs  it  protects  and  is  itself  seldom  the  site  of 
pathologic  processes.” 

\ In  addition  to  the  radiologic  evidence  of  a cal- 
: cific  deposit  in  the  region  of  the  cuff,  degenerative 
; shoulder  lesions  reveal  further  X-ray  evidence 
of  their  presence.  Irregularity  of  the  cortical 
bone  of  the  greater  tuberosity  frequently  as- 
sociated with  cystic  cavitation  and  sclerosis  in 
, and  about  the  greater  tuberosity  of  the  humerus 
! are  usual  X-ray  findings.^  Articular  surface  ero- 
( sion  of  the  head  of  the  humerus  and  loss  of  the 
I normal  outline  of  the  anatomic  neck  are  further 
I infrequent  radiologic  findings  indicative  of  a de- 
I generative  lesion. 


In  resolving  this  lesion  nature  pursues  one  of 
two  different  methods.  The  usual  is  to  absorb 
the  fluid  and  reduce  the  tension  in  the  subdeltoid 
bursa.  At  this  point  the  patient  e.xperiences  sym- 
tomatic  improvement.  The  calcium  in  the  tendi- 
nous part  of  the  cuff  is  resorbed,  partially  or 
completely.  The  resolution  is  facilitated  by  in- 
ducing revascularization,  i.e.,  needling  of  the 
area.  The  second  and  less  frequent  course  of 
events  is  rupture  of  the  material  in  the  tendon 
into  the  bursa  or  along  fascial  planes.^  Acute 
pain  is  relieved  rapidly;  however,  in  some  cases 
a severe  inflammatory  reaction  may  be  initiated. 
This  inflammatory  response  with  or  without  the 
calcific  deposit  may  lead  to  a chronically  stiff 
and  painful  shoulder. 

In  some  instances  the  calcified  deposits  may 
become  dry,  firm  and  gritty,  causing  a dull 
aching  shoulder  with  loss  of  normal  scapu- 
lohumeral rhythm  on  motion.  Pain  results  from 
mechanical  rather  than  inflammatory  irritation 
of  the  bursal  synovial  lining.  A degenerated  ten- 
don with  calcification  in  the  rotator  cuff  rubs 
constantly  between  the  humerus  and  the  acro- 
mion or  coraco-acromial  ligament.  As  a result  of 
this  mechanical  irritation  the  bursal  walls  be- 
come thickened  with  further  pinching  of  this 
sac  on  abduction  of  the  arm.  Such  cases  of  chronic 
calcified  tendonitis  usually  require  surgery  for 
their  ultimate  relief. 

Another  common  degenerative  disease  entity 
of  the  shoulder  is  adhesive  capsulitis^  or  a so- 
called  frozen  shoulder.  It  is  the  most  common 
shoulder  condition  in  the  middle-aged.  Although 
this  entity  may  follow  a calcific  deposit  in  the 
musculotendinous  cuff,  the  sequence  of  events  in 
the  development  of  this  common  shoulder  dis- 
ability is  not  always  so  clearcut.  At  present  the 
only  factor  underlying  all  frozen  shoulders  is 
disuse  or  inactivity  of  this  joint.  Such  inactivity 
may  be  a result  of  acute  or  chronic  bursitis, 
trauma,  biceps  tendonitis,  prolonged  use  of  a 
forearm  sling,  or  operative  procedures  in  or  about 
the  shoulder  with  j^rolonged  immobilization. 

{Continued  on  page  23S) 


BALL-THROWING  FRACTURE  OF  THE  HUMERUS 


MAURICE  H.  HERZMARK,  M.D. 

Washington 


FRANK  R.  KLUNE,  M.D. 

Lorton,  Va. 


'^•o— RACTURES  of  normal  bone  resulting 
from  violent  muscular  contractures  are  rela- 
tively uncommon.  When  shock  therapy  was  first 
introduced,  reports  of  fractures  from  convulsions 
were  quite  numerous,  but  fractures  of  the  hu- 
merus from  throwing  a baseball  must  be  very  in- 
frequent, considering  how  few  cases  are  reported 
in  the  literature.^  Some  of  the  standard  textbooks 
on  fractures  mention  muscular  violence  as  one  of 
the  causes  of  fractures  of  the  shaft  of  the  hu- 
merus, but  no  actual  cases  are  described.-  - ^ 


Four  cases  of  fracture  of  the  shaft  of  the  right 
humerus  were  recently  observed  in  muscular 
young  men  which  resulted  from  the  throwing  of 
a baseball  with  considerable  force.  These  men 
were  all  confined  at  the  Lorton  Reformatory,  and 
the  ball-throwing  was  part  of  regular  recreational 
activity.  In  each  instance  the  fracture  occurred 
during  the  act  of  throwing,  was  given  immediate 
care,  and  healed  with  good  functional  recovery 
without  undue  delay. 

'Fhe  mechanism  of  the  i)roduction  of  this  type 
of  fracture  is  of  interest  and  may  be  e.xplained 
on  the  basis  of  a powerful  torsion  of  the  shaft 
of  the  humerus  caused  by  the  muscles  of  the 


upper  arm  and  shoulder  holding  the  head  in  ex- 
ternal rotation  while  the  flexors  attached  to  the 
lower  end  of  the  shaft  aided  by  the  leverage  of 
the  bent  forearm  twist  the  lower  end  in  internal 
rotation.  To  understand  why  the  fracture  is 
spiral  oblique,  a review  of  the  anatomy  of  the 
humerus  is  informative. 

The  humerus  is  a long,  relatively  slender  bone, 
roughly  cylindrical,  with  a groove  which  runs 
from  within  outward,  downward  and  forward. 
The  upper  portion  of  the  bone  has  relatively 
little  muscle  attachment,  while  the  lower  part  is 
almost  completely  surrounded  with  muscle  tis- 
sue. The  insertion  of  the  deltoid  muscle  at  the 


Fig.  2.  The  line  of  cleavage  through  the  neural  groove 
The  lower  end  of  the  humerus  is  rotated  inward,  the  upper 
portion  outward. 


outer  aspect  of  the  shaft  just  above  the  middle, 
together  with  the  supra-  and  infraspinatus  mus- 
cles which  insert  about  the  greater  tuberosity 
tend  to  abduct  and  externally  rotate  the  arm, 
while  the  coracobrachialis  muscle  attaching  to  a 
goodly  portion  of  the  mesial  aspect  of  the  shaft 
aids  in  flexion  and  internal  rotation.  In  addition, 
the  powerful  biceps  and  the  brachialis  anticus 


196 


VOL.  XXI,  NO.  4 


Medical  Annals  of  the  District _oJ  Columbia 


197 


muscles  act  to  adduct,  fle.x 
and  roll  the  lower  end  of  the 
arm  inward. 

In  the  action  of  throwing 
a ball  the  arm  is  raised,  e.x- 
tended  and  e.xternally  ro- 
tated, the  elbow  is  almost 
completely  extended,  and 
the  hand  holding  the  ball  is 
thrown  back  as  far  as  pos- 
sible (fig.  1).  When  the  limit 
of  this  action  is  reached,  the 
arm  is  then  forcefully  and 
rapidly  flexed,  partially  ad- 
ducted and  internally  ro- 
tated while  the  elbow  is 
flexed,  the  forearm  par- 
tially pronated,  the  wrist 
fle.xed;  and  when  the  maxi- 
mum range  has  been  reached. 


Fig.  i.  Case  1.  (.\)  Sjiiral  oblique  fracture  through  the  shaft  of  the  right  hu- 
merus after  throwing  a baseball.  (B)  Union  after  5 weeks. 


in  his  throw,  extends  the 
arm  too  far  back,  fle.xes  the 
elbow  too  cjuickly  and  snaps 
the  action  short.  Thus,  in 
some  instances  the  adduc- 
tors and  external  rotators  do 
not  have  time  to  relax  be- 
fore the  rapidly  contracting 
f exors  and  internal  rotators, 
aided  by  the  leverage  of  the 
flexed  forearm  traveling 
through  the  arc  of  internal 
rotation  of  the  lower  end  of 
the  shaft  against  the  upper 
end  held  in  external  rota- 
tion, twist  the  lower  portion 
of  the  shaft  and  cause  a s{)i- 
ral  obliciue  fracture  through 
the  neural  groove  (fig.  2). 


the  ball  is  released  with  the  index  and  third 
fingers  guiding  in  the  diection  of  the  target.  The 
powerfully  developed  but  inexperienced  ball- 
thrower,  in  his  desire  to  get  maximum  power 


Report  of  Case.s 

Case  1.  C.  F.,  No.  8.S242,  a colored  man  28  years  old, 
with  a weight  of  178  lbs.  and  a height  of  75^  inches, 
was  in  excellent  jihysical  condition  and  very  muscular. 


198 


Ball-throwing  Fracture  of  Humerus — Ilerzmark  ami  Klune 


APRIL,  1952 


The  blood  serologic  examination  was  negative,  the 
P.M.H.  was  negative,  and  there  had  been  no  previous 
fractures  or  illnesses.  The  usual  occupation  was  cook- 
baker.  He  was  confined  to  a cell  from  June  5,  1950  to 
September  1,  1950.  For  exercise  he  did  daily  push-ups. 


Fig.  5.  Case  5.  Spiral  oblique  fracture  of  right  humerus 
immobilized  with  screws. 

increasing  the  number  until  he  could  do  200  at  a time. 
After  release  he  began  to  play  with  a soft-ball.  .After 
throwing  25  to  30  pitches,  he  increased  the  power  of  the 
throw.  After  reaching  the  maximum  of  extension,  with 
the  elbow  Hexed,  he  began  to  move  the  arm  forward  to 
throw  as  hard  as  possible.  Half-way  through  the  motion, 
he  felt  his  arm  snap  and  lost  control.  He  was  removed  to 
the  dispensary,  where  a fracture,  spiral  oblique  of  the 
humerus,  was  found  (fig.  3-.\).  .After  reduction  the  arm 
was  immobilized  in  a plaster  hanging  cast  and  excellent 
functional  result  was  obtained  (fig.  3-B). 

Case  2.  H.  H.,  Xo.  23262,  a white  man  aged  28,  was  a 
silver  fox  farmer.  His  height  was  65 f inches  and  his 
weight  was  147 J lbs.  He  was  in  good  health.  The  blood 


Kahn  test  was  4-plus.  He  was  given  antiluetic  treatment 
in  alternating  courses,  consisting  of  mepharsan  and 
bismuth  intravenously.  Several  months  after  completing 
the  treatment  he  entered  into  a contest  to  see  who 
could  throw  a baseball  the  greatest  distance.  While 
making  the  pitch  he  felt  his  right  arm  crack  and  lost 
control.  He  was  taken  to  the  dispensary  where  an  X- 
ray  film  showed  an  oblique  fracture  of  the  right  humerus 
(fig.  4-.A).  A Jones  humerus  splint  was  applied,  and  after 
5 weeks  the  bone  was  solidly  healed  with  good  function 
of  the  arm  (fig.  4-B). 


Fig.  6.  Case  4.  Siiiral  oblique  fracture  of  humerus. 

Case  3.  S.  W.,  No.  72517,  a colored  man  aged  23, 
whose  height  was  73  inches  and  whose  weight  was  153 
lbs.,  was  a mimeograph  operator.  He  was  in  excellent 
physical  condition.  The  blood  serology  test  was  negative. 
While  throwing  a baseball  he  felt  his  arm  snap.  X-ray 
fi’ms  showed  a spiral  fracture.  Manipulation  failed  to 
approximate  the  fragments  proprerly,  and  an  open  re- 
duction was  carried  out.  Muscle  tissue  was  found  in- 
terposed. The  approximated  ends  were  fixed  with  Collison 
screws  anti  the  arm  immobilized  in  plaster  (fig.  5). 
Good  union  resulted. 


VOL.  XXI,  NO.  A 


Medical  Annals  of  the  District  of  Columbia 


199 


Case  4.  A.  1'.  C.,  a white  man  whose  height  was  68  j in. 
and  whose  weight  was  146  Ihs.,  was  in  good  health.  He 
was  treated  for  syi)hilis  until  the  serologic  test  was 
negative.  A few  months  after  completion  of  the  treat- 
ment he  was  on  the  recreation  field  trying  to  throw  a 
baseball  into  the  air  as  high  as  possible.  He  felt  his  arm 
crack.  X-ray  films  showed  a spiral  fracture  through  the 
right  humerus  (fig.  6).  .A  Jones  splint  was  ai)plied  after 
reduction,  and  a good  result  was  obtained. 

Summary 

Four  cases  of  spontaneous  fracture  of  the  right 
I humerus  resulting  from  the  throwing  of  a Itall 


are  described,  with  a discussion  of  the  mecha- 
nism of  fracture.  A descri[)tion  of  the  type  of 
throw  which  involves  the  humerus  in  a powerful 
torsion  is  shown  to  lead  to  a spiral  oblique  frac- 
ture through  the  neural  groove. 

bIBLIOGR.\PHV 

1.  Clemmons,  H.  M.,  .and  H.cm.mond,  G.:  S])ontaneous  frac- 

ture of  humerus  due  to  muscle  violence.  Guthrie  Clin. 
Bull.,  1647,  17,  46. 

2.  Wilson,  P.  D.,  and  Cochrane,  W.  Fractures  and 

Dislocations.  Philadelphia:  Li])i)incolt,  1628. 

3.  Key,  J.  .\.,  and  Conwell,  H.  E.:  The  Management  of 

Fractures  and  Sprains.  St.  Louis:  Mosby,  1642. 


ART  SECTION  OF  THE  ARMY  MEDICAL  LIBRARY 


What  formerly  was  known  as  “The  Picture  Col- 
! lection”  of  the  Library  has  become  a full-fledged 
Art  Section  due  to  its  growth  in  size,  organization, 
; and  use.  The  Section,  located  in  Tampa  Hall,  across 
1 Independence  Avenue  from  the  main  Library,  has 
1 much  better  equipment  and  space  than  it  had  in 
I its  former  quarters  in  the  Annex. 

I In  1948  there  were  approximately  15,000  items  in 
!i  the  collection;  now  there  are  well  over  21,000  pic- 
|!  tures  and  nearly  13,000  negatives.  Acquisitions  dur- 
ing the  past  year  included  numerous  gifts,  such  as 
the  fine  collection  of  medical  bookplates  from  Dr. 
i Morris  Fishbein  and  a large  collection  from  Dr. 

I Webb  E.  Haymaker  of  portraits  of  neurologists  at- 
tending the  1949  International  Neurological  Con- 
gress in  Paris.  The  continuing  program  of  exchange 
j with  the  Armed  PArces  Institute  of  Pathology 
I brought  in  many  pictures  of  medical  institutions, 
and  the  Library  received  a collection  of  portraits 
. from  the  duplicates  in  the  New  York  Academy  of 
■ Medicine.  In  addition  to  these  large  gifts,  pictures 
are  acquired  through  letters  of  solicitation.  In  recent 
I months  nearly  800  pictures  of  military  and  civilian 
hospitals  and  over  500  portraits  of  Fellows  of  the 


American  College  of  Physicians  and  of  Initiates  of 
the  American  College  of  Surgeons  have  been  ac- 
quired through  this  means.  The  Art  Section’s  collec- 
tion of  portraits  of  Honorary  Consultants  to  the 
Army  Medical  Library  was  also  thus  substantially 
augmented  in  1951,  though  it  is  not  as  yet  comj)lete. 

The  staff  of  the  Armed  Forces  Institute  of  Pa- 
thology makes  frequent  use  of  the  picture  material, 
as  do  writers,  editors,  and  publishing  companies. 
The  greatest  number  of  calls  are  for  portraits  of 
physicians  of  the  past  and  present  and  of  military 
medical  officers  and  nurses.  Next  in  frequency  are 
requests  for  historical  material,  for  hospital  pictures, 
especially  hospitals  in  Civil  War  times,  and  for 
medical  subjects.  The  steady  increase  in  service  to 
the  public  seems  proof  of  the  value  of  the  Art  Sec- 
tion. 

The  Library  is  always  grateful  to  receive  addi- 
tional pictorial  material  of  medical  interest.  Gift 
pictures,  or  information  on  pictures  available  for 
purchase,  should  be  addressed  to  the  Catalog  Divi- 
sion, Army  Medical  Library,  Seventh  Street  and 
Independence  .Avenue,  S.W.,  Washington  25,  1).  C. 

— Army  Medical  Library  Xews,  February  1953 


i 


REHABILITATION  OF  THE  UPPER  EXTREMITY 
FOLLOWING  POLIOMYELITIS 


Report  of  a Case 


^XTEXSIVE  paralysis  of  an  upper  ex- 
tremity is  a not  infrequent  sequel  of  a severe 
attack  of  anterior  poliomyelitis.  Paralysis  of  the 
shoulder  muscles,  weakness  and  inability  to  con- 
trol the  forearm,  elbow  and  wrist,  and  absent 
apposition  of  the  thumb  are  serious  problems 
which  cannot  be  overcome  by  present  methods 
of  bracing  to  produce  a functional  extremity. 
Fortunately,  we  do  have  available  numerous 
operative  procedures,  involving  muscle  trans- 
plants, osseous  surgery,  use  of  fascia,  etc.,  which 
may  add  a good  deal  of  function  to  a severely 
disabled  extremity.  However,  each  case  is  an 
individual  problem  which  requires  most  careful 
planning  and  meticulous  attention  to  every  de- 
tail to  achieve  a maximum  result.  Not  only  must 
the  surgery  be  well  e.xecuted  and  casts  applied 
with  preciseness,  but  full  cooperation  must  be 
secured  froni  the  physical  therapist,  the  parents, 
and  the  patient.  They  form  a most  important 
cog  in  the  postoperative  phase  of  every  rehabili- 
tation program.  The  success  of  many  surgical 
procedures,  and  especially  tendon  transplants, 
is  strongly  dependent  upon  the  postoperative 
care,  including  proper  protective  bracing,  well 
supervised  physical  therapy,  and  supervised 
home  activities. 

The  selection  of  the  proper  time  for  the  various 
rehabilitation  procedures  is  essential  to  their 
eventual  success.  Although  tendon  surgery  can 
generally  be  performed  at  an  earlier  age  than  os- 
seous surgery,  it  must  be  deferred  until  the  child 
can  cooperate  fully  in  the  postoperative  exer- 
cises which  are  so  important  to  the  transplanted 
muscle.  Fusion  oj)erations  must  await  sufficient 
bony  development,  usually  not  before  8 years 


EVERETT  J.  GORDON,  M.D.,  F.A.C.S. 

Washington 


of  age.  In  the  case  herein  reported  the  first  at- 
tack of  poliomyelitis  occurred  at  the  age  of  3. 
It  was  necessary  to  defer  operative  treatment 
until  the  age  of  9,  making  use  of  various  types  of 
shoulder  and  thumb  ojiponens  braces  to  mini- 
mize deformity,  and  physical  therapy  to  prevent 
complicating  contractures,  until  he  was  able  to 
cooperate  fully  and  to  undergo  the  required  os- 
seous surgery. 

Report  of  C.xse 

F.  M.,  a white  boy,  was  admitted  to  Children’s 
ttospital,  September  .t,  1044  for  observation  for  acute 
poliomyelitis,  but  was  discharged  24  hours  later  with  all 
studies  negative.  He  had  been  admitted  earlier  the  same 
year  for  a few  days  for  Ludwig’s  angina  but  otherwise  had 
previously  incurred  no  unusual  illnesses.  On  .\ugust  3, 
1945  he  was  again  admitted  for  observation  for  poliomye- 
litis with  characteristic  clinical  and  laboratory  signs, 
including  paralysis  of  the  legs,  stiffness  of  the  neck,  and 
a severe  paralysis  of  the  entire  right  upper  extremity. 
A diagnosis  of  poliomyelitis  was  quickly  established  and 
treatment  begun  with  moist,  warm  packs  to  regions  of 
muscle  spasm  and  tenderness,  support  for  the  paralyzed 
right  upper  extremity,  and  therapeutic  muscle  reedu- 
cation. He  was  discharged  September  8,  1945,  e.xami- 
nation  then  revealing  complete  paralysis  of  the  right 
deltoid  and  external  rotator  muscles,  severe  atrophy  of 
the  right  shoulder  and  upper  arm,  poor  flexors  and  ex- 
tensors of  the  right  shoulder,  and  faint  traces  of  opponens 
function  in  the  right  thumb.  few  weeks  later  a com- 
plete muscle  check  performed  in  the  physical  therapy 
clinic  revealed  no  residual  paralyses  in  the  legs,  neck  or 
back  but  the  following  findings  in  the  right  upper  ex- 
tremity (scale  O-lOO): 

Thumb:  Opponens — faint  trace 
-Adduction — good 

W’rist : Extensors — excellent 
Flexors — good 


200 


VOL.  XXI,  NO.  4 


Medical  Annah  of  the  District  of  Columbia 


201 


Elbow:  Supinator — 70 
Pronator — 60 
Flexors — poor 
Extensors — fair 

Shoulder:  External  rotators — 30 
Internal  rotators — 30 
Abductor — 0 
Adductor — 20 
Flexors — 20 
Extensors — 20 
Pectoralis  minor — 0 
Subscapularis — 60 

He  was  followed  in  the  outpatient  clinic  with  frequent 
physical  therapy  of  the  right  upper  extremity,  which  was 
supported  with  a shoulder  harness  and  a small  opponens 
brace  for  the  thumb.  Examination  2 years  after  the 
onset  of  his  illness,  September  1947,  revealed  zero  func- 
tion in  the  supraspinatus,  deltoid  and  biceps  muscles, 
traces  of  teres  major  and  minor  muscles,  a poor  triceps, 
good  trapezius,  and  zero  function  in  the  opponens  of  the 
thumb.  .'\t  this  time  it  was  recommended  that  a shoulder 
fusion  be  performed  at  the  approximate  age  of  8 years, 
after  sufficient  bony  development. 

On  June  16,  1949  marked  relaxation  of  the  shoulder 
joint  capsule  with  evident  subluxation  was  first  observed 
and  noted,  as  well  as  lack  of  return  of  any  function  in  the 
thumb  opponens.  .‘\t  this  time,  after  presentation  of  the 
case  to  the  monthly  poliomyelitis  conference,  a full 
program  of  surgical  treatment  to  rehabilitate  the  useless 
extremity  was  outlined.  This  consisted  of  fusion  of  the 
shoulder  joint  in  90°  abduction  and  30°  forward  flexion, 
flexor  muscle  transplant  at  the  elbow,  and  opponens 
transplant  for  the  thumb. 

.•Ml  of  the  surgical  procedures  were  completed  at 
Children’s  Hospital.  The  first,  arthrodesis  of  the  right 
shoulder,  was  performed,  September  19,  1949.  Marked 
relaxation  of  the  joint  capsule  with  little  or  no  residual 
deltoid  muscle  tissue  was  noted.  Fusion  was  secured  by 
denuding  the  humeral  head  and  glenoid  fossa  of  all 
articular  cartilage,  and  then  bending  an  osteotomized 
acromion  process  downward  to  fit  into  a wedge-shaped 
notch  cut  into  the  greater  tuberosity  held  by  retaining 
chromic  catgut  sutures.  .\  position  of  90°  abduction  and 
I 30°  forward  flexion  of  the  arm  was  maintained  by  trans- 
1 fixing  the  joint  with  a short  Steinman  pin  inserted  below 
j the  operative  incision,  followerl  by  the  application  of  a 
I shoulder  spica  cast.  The  pin  was  removed  through  a 
I window  cut  in  the  cast  8 weeks  later,  and  the  entire  cast 
removed,  January  5,  1950.  Clinical  and  X-ray  exami- 
nation revealed  firm  bony  fusion;  light  exercises  to  develop 
the  trafjezius  muscle  were  then  begun. 

Two  weeks  later  he  was  able  to  abfluct  the  right 
shoulder  girdle  to  45°  without  i)ain  and  could  easily 


bring  the  arm  down  to  his  side.  Physical  therapy  was 
increa.sed,  and  within  2 months  he  could  abduct  the  right 
shoulder  to  65°,  using  scapular  rotation.  He  was  then 
ready  for  his  next  surgical  procedure,  to  be  done  during 
Easter  vacation  recess. 

On  .■\pril  5,  1950  a Steindler  flexorplasty  procedure^ 
was  performed  on  the  right  elbow,  with  transplantation 
of  the  common  flexor  tendon  of  origin  2 inches  proximally 
onto  the  humerus,  a drill  hole  and  small  wire  suture  being 
used  to  secure  good  anchorage,  with  the  elbow  held  in 
80°  flexion,  mid-supination  and  pronation  by  a long  arm 
cast.  The  ulnar  nerve  was  also  transferred  anteriorly 
to  avoid  compression  from  the  displaced  flexor  tendon. 
After  removal  of  the  cast  4 weeks  later  intensive  physical 
therapy  was  instituted  to  develop  the  flexor  muscles 
(rated  good  preoperatively)  and  to  extend  the  elbow. 
Maximum  extension  obtainable  was  to  135°,  which  was 
believed  to  be  optimum  if  sufficient  power  to  flex  the 
elbow  was  to  be  retained.  However,  it  soon  became 
apparent  that  there  was  a marked  pronator  supremacy 
over  his  weakened  supinators,  displayed  when  the  newly 
acquired  ability  to  flex  the  elbow  was  used  to  bring  his 
hand  to  the  mouth. 

The  excellent  i)rogress  made  was  reported  to  the 
Poliomyelitis  Conference  June  21,  1950,  and  it  was  the 
consensus  that  the  elbow  and  shoulder  operations  had 
resulted  in  marked  improvement.  It  was  recommended 
that  rehabilitation  be  continued  with  surgery  to  correct 
the  f^ronator  supremacy  of  the  forearm  and  opponens 
weakness  of  the  thuml).  .\ccordingly,  on  .\ugust  9,  1950 
an  opponens  transplant  was  performed  by  the  method  of 
Steindler,^  in  which  the  tendon  of  the  flexor  pollicis 
longus  is  split  longitudinally  and  the  lateral  half  made  to 
encircle  the  proximal  phalanx  of  the  thumb.  .■\t  the  same 
time  the  pronator  teres  was  partially  released  to  diminish 
the  pronator  supremacy  in  the  right  forearm.  The  cast 
was  removed  1 month  later  and  active  physical  therapy 
once  more  instituted.  Within  a month  there  was  excellent 
opponens  action  in  the  thumb,  but  the  pronator  teres  was 
still  overactive  for  the  weak  supinators.  Three  months 
after  the  opponens  operation  a clinical  examination  re- 
vealed activ'e  shoulder  aljduction  from  0 to  75°,  elbow 
flexion  to  60°,  extension  to  135°,  full  opponens  power, 
and  20°  flexion  in  the  interphalangeal  joint  of  the  thumb. 

'I'he  final  operation  in  the  rehabilitation  of  this 
weakened  upper  extremity  was  a supinator  transplant, 
done  December  19,  1950  at  the  beginning  of  the  holiday 
recess.  The  tendon  of  the  fle.xor  car{)i  ulnaris  was  freed 
and  transplanted  oblitjuely  across  the  dorsum  of  the 
forearm  to  the  dorsal  aspect  of  the  radius  at  the  wrist 
(Steindler*).  When  the  plaster  was  removed  a month 
later,  immediate  sui)ination  was  observed.  .A  leather 
night  si)lint  was  fashioned  to  {)reserve  this  newly  gained 


202 


Rehabilitation  in  Poliomyelitis — Gordon 


APRIL,  1952 


Fig.  1.  Final  result  (double  exposures): 
(.\)  range  of  shoulder  and  elbow  motion; 

(B)  range  of  pronation  and  supination; 

(C)  demonstrating  full  opponens  action  of 
thumb. 


supination  and  to  protect  it  while  active  and  passive  ex- 
ercises were  improving  the  strength  of  the  transplant. 
On  February  8,  1951  examination  revealed  excellent 
function  in  the  supinator  transplant  and  he  was  now  able 
to  bring  objects  to  his  mouth  without  difficulty  and 
without  the  hand  suddenly  “flopping  over’’  from  un- 
opposed pronator  action.  Flexion  of  the  interphalangeal 
joint  of  the  thumb  also  increased  to  35°.  The  following 
month  he  made  the  first  team  while  playing  basketball 
at  school,  and  it  was  only  later  that  the  coach  noticed 
that  his  unorthodox  style  was  due  to  a physical  handicap. 

On  examination  in  .August,  1951  there  was  80°  shoulder 
abduction,  elbow  motion  from  60  to  135°,  fair  supination, 
and  fair-plus  pronation  of  the  forearm,  30°  flexion  of  the 
interphalangeal  joint  of  thumb,  excellent  opponens  of 
the  thumb,  and  good  fle.xors  and  extensors  of  the  fingers 
and  wrist  (fig.  1).  He  was  able  to  perform  all  of  his 
flaily  necessities  without  aid  (see  fig.  2),  attend  school 
regularly,  and  participate  in  regular  school  activities 
and  sports. 

Comment 

This  case  has  been  presented  to  illustrate  what 
can  be  done  to  rehabilitate  an  apparently  hope- 
lessly damaged  upper  e.xtremity  as  a residual  of 
anterior  poliomyelitis.  A properly  planned  pro- 
gram which  includes  physical  therapy  combined 
with  well  selected  surgical  procedures,  unhurried 
and  interspersed  with  sufficient  recuperative  in- 
tervals, can  convert  a useless  extremity  into  a 
functional  unit  which  may  remove  the  individual 
from  the  handicapped  group  and  permit  normal 
activities  and  occupation.  In  the  case  reported 
the  right  upper  extremity  was  sufficiently  im- 


proved by  the  multiple  surgical  procedures  to 
permit  active  function  and  occupational  use. 
Further  progress  is  to  be  expected  with  con- 
tinued use  of  the  rehabilitated  extremity.  The 


Fig.  2.  .\  useful  extremity. 

stimulated  mental  outlook  is  another  important 
result  not  to  be  overlooked. 

{Continued  on  page  238) 


Maybe  last  month’s  “page”  was  a little  preachy,  somewhat  serious  and  weighty,  but 
worthy  of  thought,  nonetheless.  This  time,  however,  spring  has  come.  A benign  and  con- 
siderate deity,  realizing  that  we  have  taken  all  the  bad  weather,  flu,  and  daily  pressure  we 
could  stand,  has  provided  some  let-up  and  I hope  a chance  for  rela.xation. 


The  golf  clubs  are  out,  and  I hope  to  bring  my  score  down  from  115  to  105  (same  hope 
I’ve  had  for  the  last  several  years).  The  garden  is  full  of  color  from  bulbs,  and  flowering  shrubs. 
I suspect  that  soon  they  will  need  separating  and  pruning.  The  grass  is  also  growing  again, 
I’m  afraid.  I’m  not  sure  whether  the  lawn  mower  or  putter  will  win  out  each  Thursday  after- 
noon and  week  ends. 


Fish  are  running  in  the  river.  The  Skyline  Drive  is  fresh  green.  W illiamsburg,  Fredericks- 
burg, Charlottesville,  and  Georgetown  are  showing  their  homes  and  gardens.  Summer  plans 
are  beginning  to  shape  up — the  mountains,  the  shore,  Canada.  Then  the  fall  with  brisk  tingle, 
rainbow  foliage,  squirrel-,  bird-,  and  later  deer-hunting.  Then  winter  again. 


This  flow  of  words,  brought  on  by  spring,  probably  needs  a good  dose  of  sulfur  and 
molasses.  Actually,  it’s  an  appreciation  for  hopes  of  rela.xation  and  recreation.  I’m  sure  no 
profession,  as  a whole,  pushes  harder,  works  longer  hours,  sees  more  troubles  than  does  the 
medical  profession.  Nor  in  any  other  jjrofession  is  the  “coronary  harvest”  so  large  and  so 
early. 


A periodic  or  occasional  surcease  in  the  form  of  si)orts,  hobbies,  and  travel  is  of  paramount 
importance  to  the  busy  doctor.  So  next  year,  I’m  going  to  play  golf  three  times  a week.  I’m 
going  to  take  piano  lessons;  and  learn  to  sing  instead  of  just  whistle.  I shall  take  that  trip  to 
New  Orleans,  Hawaii,  Banff  (or  Hyattsville).  I shall  work  less  and  play  more  ...  I keep 
telling  myself,  as  I have  for  the  past  several  years.  You  can’t  blame  me  for  dreaming. 


CARDIAC  ARREST 


There  is  today  more  interest  than  ever  before 
in  the  causes  and  treatment  of  cardiac  arrest 
during  surgery.  From  many  of  the  articles  now 
constantly  appearing  it  would  seem  that  this  is 
an  increasing  cause  of  catastrophe.  However,  it 
was  recognized  and  competently  evaluated  near 
the  beginning  of  the  century. 

In  the  broadest  sense,  of  course,  any  patient 
who  dies  does  so  in  cardiac  arrest.  The  inclusion 
of  anesthetic  overdosage,  ano.xia  from  any  cause, 
air  embolism,  coronary  occlusion,  etc.  among  the 
causes  of  clinical  cardiac  arrest  is  justified  on 
physiologic  grounds.^ 

More  specific  and  limited  consideration  of 
cases  in  which  almost  instantly  the  heart  actually 
loses  its  pumping  capacity  revolves  around  re- 
sponse to  some  such  drugs  as  epinephrine  (even 
if  manufactured  in  the  patient),  chloroform, 
ethyl  chloride,  cyclopropane,  etc.,  and  to  reflex 
response  to  some  surgical  or  anesthetic  manipu- 
lations. 

Since  early  reports  of  cases  treated  by  cardiac 
massage  beginning  more  than  a half  century  ago, 
most  writers  have  stressed  that  immediate  diag- 
nosis is  the  key  to  successful  treatment.'*'^ 

Less  stressed,  but  perhaps  even  more  impor- 
tant, is  the  fact  that  the  careful  observation 
necessary  for  such  early  diagnosis  should  make 
it  possible  in  most  cases  to  recognize  impending 
rather  than  actual  collapse. 

' Green:  Lancet,  1906,  2,  1708. 

2 White,  C.  S.:  Surg.,  Gynec.  & Obst.,  19W,  9,  388. 

3 Bonica,  J.;  Current  Researches  in  .\nesth.  & .\nalg., 
1952,  31,  1. 

^ Beck,  C.  S.,  and  R.and,  H.  J.:  1949,  141,  1230. 

® Bost,  T.  C.:  Am.  J.  Surg.,  1952,  83,  135. 


It  may  be  true  that  in  an  average  general 
surgical  service  as  many  as  1 patient  in  a thou- 
sand may  die  under  anesthesia,  and  in  this  broad 
sense  from  cardiac  arrest.  It  is  also  true,  how- 
ever, that  in  some  especially  good  series  the 
incidence  for  many  thousands  of  patients  is  only 
a tenth  as  great,®  while  in  some  authentic  series 
the  incidence  may  be  5 or  6 times  as  great. 

This  extreme  variability  on  anesthesia  services 
argues  forcefully  that  management  is  the  major 
factor.  Such  argument  does  not  detract  from  the 
force  of  the  contention  that  whatever  the  cause 
of  cardiac  arrest  it  must  be  followed  by  immediate 
diagnosis  and  effective  artificial  respiration  plus 
artificial  circulation,  all  within  a critical  period 
of  about  3 minutes  if  the  best  chance  of  survival 
is  to  be  given  the  patient. 

In  our  teaching  we  are  faced  with  the  dilemma 
of  whether  to  stress  that  good  management  will 
prevent  most  cases  of  cardiac  arrest  and  elabo- 
rate on  this  viewpoint,  or  to  teach  that  the  major 
objective  in  planning  is  to  prepare  as  many  as 
possible  to  assume  at  need  the  duties  of  cardiac 
massage. 

Continued  effective  heart  function  is  primarily 
dependent  upon  maintenance  of  an  adecjuate 
oxygen  reserve.  This  means  in  turn  that  coronary 
pressures  must  exceed  40  mm.  Hg  and  all  normal 
channels  remain  patent  for  effective  blood  per- 
fusion of  the  muscle.^  It  means  also  that  the 


® Moused,  L.  H.,  Kreiselman,  J.,  and  Stubbs,  D.;  .\nes 
thesiology,  1946,  7,  69. 

’ Crile,  G.  W.:  .\nemia  and  Resuscitation.  New  York: 
Ajipleton,  1914. 


Opinions  expressed  in  contributions  to  the  Editorial  Section  are  those  of  the  writers  and 
do  not  necessarily  reflect  the  views  of  The  Medical  Society  of  the  District  of  Columbia. 


VOL.  XXI,  NO.  4 


Medical  Annals  of  the  District  of  Columbia 


205 


perfused  blood  must  have  been  previously  oxy- 
genated in  the  lungs,  necessitating  prior  pulmo- 
nary ventilation. 

A clear  understanding  of  the  underlying  physi- 
ology will  enable  each  surgeon  or  anesthesiologist 
to  decide  for  himself  how  to  balance  his  study  of 


careful  management  versus  resuscitative  tech- 
nics. It  will  perhaps  lead  again  to  the  old  saying 
that  “An  ounce  of  prevention  is  worth  a pound 
of  cure.” 

c.  s.  w. 

D.  S. 


BARBITURATES  AND  THE  PHYSICIAN 


With  considerable  frequency  the  daily  papers 
carry  stories  of  suicides  committed  by  means  of 
“sleeping  tablets” — almost  always  barbiturates. 
This  is  one  of  the  ways  in  which  the  abuse  of  this 
group  of  drugs  is  brought  dramatically  to  public 
attention,  and  it  is  not  strange  that  occasional 
demands  are  heard  that  the  barbiturates  be 
brought  under  the  provisions  of  the  Harrison  Act 
or  that  their  use  be  otherwise  controlled  Fed- 
erally. 

The  extent  to  which  these  drugs  are  improperly 
used  cannot  be  well  assessed.  It  is  estimated  on 
good  authority  that  no  less  than  three  billion 
doses  are  sold  yearly  in  this  country!  Even  with 
all  of  the  cases  in  which  these  sedatives  are  pre- 
scribed for  convulsive  disorders  and  for  occasional 
insomnia,  it  takes  no  vivid  imagination  to  con- 
sider an  average  of  20  doses  per  man,  woman  and 
child  as  far  in  excess  of  medical  needs. 

Whether  the  barbiturates  are  truly  addictive 
in  the  sense  of  bringing  about  such  physiologic 
changes  that  deprivation  causes  physical  symp- 
toms is  perhaps  a question  of  semantics.  Certain 
it  is  that  there  are  many  unstable  persons  who 
easily  become  habituated,  and  who  develop  a 
pathologic  dependence  on  sedative  drugs,  such 
as  the  barbiturates  and  alcohol,  or  worse  still,  a 
combination  of  those  two.  Although  many  of  the 
neurologic  symptoms  of  barbiturate  intoxication, 
such  as  tremors  and  incoordination,  tend  to  be 
transitory,  permanent  psychic  damage  may  de- 
velop in  the  habitue,  and  accidental  death  from 
overdosage  is  all  too  common. 

Most  states  now  require  pharmacists  to  dis- 


pense the  barbiturate  drugs  only  on  a physician’s 
prescription.  To  apply  the  Harrison  Act  to  these 
drugs  would  make  their  legitimate  use  extremely 
difficult,  and  it  probably  is  not  desirable,  at  least 
until  other  methods  of  control  have  been  tried 
and  have  failed. 

The  most  important  factor  in  the  chain  of  con- 
trol is  the  physician  himself,  and  next  to  him  the 
pharmacist.  The  physician  should  be  alert  to  the 
dangers  of  barbiturate  habituation,  and  espe- 
cially to  the  tricks  employed  by  the  habitue.  He 
should  be  careful  to  prescribe  only  enough  for 
the  particular  use  and  try  to  avoid  giving  the  pa- 
tient the  opportunity  to  accumulate  a large  num- 
ber of  tablets  or  capsules.  It  is  doubtful  whether 
it  is  desirable  to  permit  refills;  indeed  it  would  be 
much  preferable  to  mark  each  prescription  “not 
to  be  refilled.”  The  pharmacist  should  sell  only 
on  a written  prescription,  and,  if  a prescription 
is  presented  for  refilling,  he  should  ascertain  from 
the  physician  that  there  is  no  objection. 

The  present  state  of  thinking  on  the  part  of 
Federal  officials  appears  to  be  that  the  control 
of  traffic  in  barbiturates  is  a proper  state  func- 
tion, and  that  by  appropriate  state  legislation, 
plus  the  cooperation  of  physicians,  pharmacists, 
and  the  pharmaceutics  manufacturers,  the  use  of 
these  drugs,  most  useful  in  their  place,  can  be 
limited  to  proper  medical  use.  If,  later  on,  the 
demand  for  Federal  restriction  is  renewed,  the 
medical  and  pharmaceutic  professions  may  per- 
haps look  to  their  own  actions  if  they  would 
seek  to  fix  the  blame. 


W.  O. 


206 


Editorials 


APRII.,  1952 


HOW  SHOULD  WE  TREAT  ADOLESCENCE? 


Song  and  story  attribute  advantages  to  youth 
which  it  does  not  deserve.  Youth  is  said  to  be 
carefree  and  to  be  the  happiest  time  of  life. 
Nostalgic  reference  is  made  to  the  “good  old 
days,”  when  in  reality  most  of  us,  of  whatever 
age,  are  enjoying  the  “good  old  days”  right  now. 
At  the  present  time  we  are  taking  the  bitter 
with  the  sweet  in  about  ecpial  proportions,  but 
the  bitter  seems  to  be  more  frequent  because  it 
impresses  us  more.  The  sweet  is  not  so  much 
appreciated  until  time,  plus  imagination,  allows 
us  to  view  the  past  with  rose-colored  spectacles. 
The  sharj)  outline  of  events  which  have  happened 
is  softened,  and  the  tendency  we  all  have  to 
eliminate  the  unpleasant  occurrences  of  life  from 
our  minds  causes  the  bitter  experiences  to  be 
forgotten. 

I deny  that  youth  is  an  unalloyed,  pleasant 
experience,  and  I think  that  adolescence  is  the 
most  trying  period  of  life. 

I )o  you  remember  the  years  you  lived  between, 
let  us  say,  13  and  20?  You  have  arrived  at  pu- 
berty and  have  left  childhood  behind.  Sexual 
awakening  has  occurred,  and  you  do  not  under- 
stand it.  You  are  confused  and  possibly  afraid. 
\'ou  worry  because  you  feel  that  you  are  dif- 
ferent from  others.  You  keep  your  thoughts  and 
feelings  to  yourself  because  you  hesitate  to  con- 
fide in  others.  You  are  neither  fish  nor  flesh. 
^'our  voice  has  become  deeper,  and  probably  you 
find  it  necessary  to  remove,  from  time  to  time, 
the  down  which  recurs  on  your  face.  Yet  you 
are  not  a man.  You  want  to  act  like  a man  but 
you  are  not  treated  like  one.  People  misunder- 
stand you.  You  have  not  yet  acquired  the  knowl- 
edge and  experience  upon  which  to  base  judg- 
ment. Therefore,  you  make  many  errors  in  judg- 
ment. You  are  aware  of  this  and  attempt  to 
compensate  by  aggressiveness  and  a “know-it- 
all”  attitude. 

Your  father  attempts  to  make  you  his  pal. 
You  fish  and  golf  with  him.  You  realize  that  it 
is  impossible  to  be  his  pal.  Your  ideas  do  not 


jibe,  and  there  always  comes  the  time  when  he 
must  exert  his  authority.  This  spoils  the  rela- 
tionship. As  a child  he  was  your  idol.  You  see 
him  now  with  his  friends.  You  compare  him  to 
them  and  conclude  that  he  is  just  about  average. 
Maybe  you  are  disillusioned  when  you  hear  him 
relate  a risque  story,  or  when  he  lingers  too 
long  at  the  19th  hole.  You  no  longer  attempt  to 
imitate  him,  and  you  substitute  your  own  ideas 
and  judgments  for  his.  Too  frequently  these  are 
found  to  be  wrong.  You  long  to  be  understood 
by  others  and  even  by  yourself. 

You  are  awkward  with  girls.  You  say  the 
wrong  thing.  You  would  like  to  be  popular,  but 
sooner  or  later  your  judgment  errs  again  and 
you  are  held  up  to  ridicule.  Your  allowance 
somehow  does  not  last  long  enough.  You  are 
broke  most  of  the  time  and  you  are  embarrassed 
in  the  company  of  boys  whose  fathers’  wealth 
allows  them  to  spend  more  money  and  to  drive 
their  own  car. 

At  home  you  are  directed  to  do  this  and  are 
forbidden  to  do  that,  without  explanation  of  the 
why's  and  wherefore' s.  Nobody  asks  your  advice. 
You  are  reprimanded  for  acts  which  appeared 
to  you  to  be  correct,  and  jiraise  is  lacking  when 
you  have  done  the  right  thing. 

As  you  approach  20  things  begin  to  clear  up. 
You  are  consulted  on  matters.  Knowledge  and 
e.xperience  are  catching  up,  and  your  judgment 
improves.  You  are  likely  to  entertain  the  senti- 
ments of  the  21-year-old  who  was  overheard 
saying  to  his  companions  that  his  father  was  a 
remarkable  man  and  that  he  learned  more  in 
the  past  year  than  anyone  ever  heard  of. 

Adolescence  is  an  age  of  sensitiveness,  misun- 
derstanding, apprehension  and  fear.  The  affairs 
of  life  are  very  serious  at  that  age,  and  what 
later  would  be  mere  disappointments  are  trage- 
dies. Repeated  rebuffs  and  criticism  cause  heart- 
burnings and  make  introspective,  anti-social 
characters  who  later  may  become  Communists 
or  law-breakers. 


VOL.  XXI,  NO.  4 


Medical  Annals  of  the  District  of  Columbia 


207 


.Adults  therefore  should  study  adolescents  and, 
remembering  their  own  e.xperience,  treat  them 
with  deference  and  try  to  understand  their  prob- 
lems. Correction  should  be  accompanied  with 
free  explanation.  Tact  and  consideration  should 
be  exercised,  and  the  adolescent  should  take 
part  in  family  conferences  and  be  listened  to 
with  respectful  attention.  The  relationship  of 
father  and  son  should  be  one  of  mutual  respect, 
with  the  maintenance  of  dignity  by  the  parent 
and  proper  regard  for  authority  by  the  son.  Treat 
the  adolescent  as  an  adult  and  expect  him  to 
respond  by  attempting  to  live  up  to  your  ap- 


parent estimate  of  him.  You  will  not  be  disap- 
pointed. Encourage  confidences  and  be  ready 
with  sympathetic  advice,  which  will  include  the 
difference  between  right  and  wrong.  Instil  the 
fact  that  honesty  is  the  best  policy,  and  that 
deception  and  corner-cutting  can  usually  lead 
to  the  loss  of  regard  of  other  people,  and  to  the 
unhappiness  of  the  person  who  practices  it. 

Proper  treatment  of  the  adolescent  will  result 
in  making  him  a good  citizen.  You  can  make  his 
adolescence  happy. 

I J.4MES  A.  Gannon,  M.I). 


an.  iCli  0^ 


BY  THE  OBSERVER 


In  his  reflections  on  the  state 
of  society,  your  Observer  has  of- 
ten thought  how  much  easier  life 
is  for  extroverts,  and  how  few  of  them  he  knows, 
especially  among  those  with  whom  he  is  closely 
associated  in  the  Medical  Society.  As  a matter 
of  fact,  most  of  his  associates  are  thoughtful, 
conscientious  physicians  heavily  burdened  with 
their  many  responsibilities.  It  is  not  in  their 
natures  to  take  these  lightly,  and  being  of  a 
serious  turn  of  mind  himself,  your  Observer  is 
grateful  that  this  is  so. 

There  would  be  some  hesitation  on  your  Ob- 
server’s part  in  proceeding  further  with  these 
comments  were  it  not  for  the  fact  that  one  of  the 
ablest  and  most  serious-minded  officers  the  So- 
ciety has  had,  will  soon  relinquish  most  of  his 
official  duties.  He  will  not,  as  most  former  Pres- 
idents, become  a member  of  the  Executive  Board. 
While  your  Observer  does  not  pretend  to  have 
a complete  knowledge  of  Hr.  Frank  I).  Costen- 
bader’s  activities  he  can  testify  to  the  fact  that 
no  “chief  executive”  of  our  Society,  in  his  recol- 
lection, has  been  so  burdened  with  official  duties 
as  he  has,  and,  furthermore,  none  has  dealt  with 
them  more  adequately. 


No  member  needs  to  be  told  that  serious 
problems  have  confronted  the  Society  since  Dr. 
Costenbader  took  over.  Inescapably  he  has, 
therefore,  participated  in  innumerable  meetings, 
devoted  a tremendous  amount  of  time  to  discus- 
sion of  more  acute  problems,  attended  a great 
variety  of  conferences,  and  taken  an  active  part 
in  a number  of  ambitious  undertakings  such  as 
the  Annual  Scientific  Assembly,  the  Mid- 
winter Seminar,  and  the  Conference  on  Medical 
Teaching  Technics.  As  if  this  were  not  enough. 
Dr.  Costenbader  has  also  been  an  important 
factor  in  the  operation  of  the  Society’s  prepay- 
ment plan.  Medical  Service.  He  was  President 
of  the  Board  of  Trustees  of  the  Service  until  he 
became  head  of  the  Medical  Society  on  July  1, 
1951.  Since  then  he  has  been  a member  of  the 
Service’s  Board.  While  he  is  giving  up  most  of  his 
Society  activities,  he  projioses  to  see  the  Service 
through  its  growing  pains,  and  then  he  hopes  to 
have  some  time  for  his  personal  affairs. 

Your  Observer  does  not  want  to  give  the  im- 
pression that  Dr.  Costenbader  has  considered  all 
his  duties  as  the  Medical  Society’s  President  un- 
pleasant. In  fact,  like  all  Presidents,  he  has 
enjoyed  many  fine  relationships  which  would 


It's  a 
Rugged 
Life 


208 


In  and  Out  of  Focus — Observer 


APRIL,  1952 


never  have  existed  were  it  not  for  the  position  to 
which  he  was  elected.  And  then  there  is  the 
honor  of  having  been  chosen  President  by  his 
fellow  physicians,  which  is  something  always  to 
be  cherished. 

Perhaps  your  Observer  should  now  state  the 
point  of  these  observations,  which  is  simply  to 
lift  the  veil  a little  so  that  our  membership  will 
have  some  appreciation  of  what  being  President 
of  our  Society  means  to  a conscientious,  hard- 
working doctor.  It  is  not  all  honor  and  glory  by 
any  means.  It  is  a rugged  life. 

★ 


. - As  every  oldster  knows,  time 

A Career  , . • , , 

t p . accelerates  its  tempo  with  ad- 
oj  Service  * 

vancing  years.  Before  one  is 

aware  of  it,  one’s  contemporaries  are  snuffed  out, 
and  one  begins  to  speculate  who  will  be  next  to 
go.  While  these  are  not  particularly  happy 
thoughts,  they  must  have  been  uppermost  in 
the  minds  of  many  when  the  death  of  Dr.  Coursen 
Baxter  Conklin  became  known.  Dr.  Conklin  is 
the  last  of  several  prominent  physicians  who 
have  laid  down  their  burdens  in  the  past  year. 

Because  of  circumstances  over  which  he  had  no 
control,  your  Observer  did  not  become  ac- 
quainted with  the  real  Dr.  Conklin  until  some 
years  after  succeeding  him  as  Secretary  of  the 
District  Medical  Society.  The  occasion  finally 
presented  itself  on  a journey  to  Chicago  where 
Dr.  Conklin  rejiresented  our  Society  as  delegate 
to  the  American  Medical  Association.  Any  lack 
of  understanding  which  had  previously  existed 
was  wiped  away  in  a heart-to-heart  talk. 

It  was  at  that  time  your  Observer  discovered 
the  real  worth  of  his  predecessor.  He  learned 
that  here  was  a kindly,  sincere  and  humble  man. 
There  was  no  ])retense  about  him;  in  fact.  Dr. 
Conklin  was  inclined  to  be  too  modest  about  him- 
self, his  abilities  and  accomplishments.  He  pos- 
sessed virtues  that  many  of  his  fellows  might 
well  have  envied-  patience,  understanding  and 
tolerance. 

d'o  many  of  the  younger  members  of  the  So- 


ciety, Dr.  Conklin  is  merely  a name.  In  reading 
of  his  death  they  discover  for  the  first  time  that 
he  had  been  Secretary  of  the  District  Medical 
Society  for  16  years  beginning  in  1922.  This  was 
a period  of  great  growth  and  Dr.  Conklin  carried 
on  his  duties  with  zeal  and  diligence  despite  the 
demands  of  his  practice.  He  established  the 
AIedical  Annals,  which  has  since  become  such 
an  excellent  state  medical  society  publication. 
He  also  organized  the  first  office  staff  employed 
by  the  Society. 

After  his  retirement  as  Secretary  in  1938,  there 
was  a five-year  period  of  inactivity.  In  1943  he 
became  a delegate  to  the  AMA,  a post  which 
he  was  to  hold  for  six  years. 

.\s  your  Observer  wrote  on  the  occasion  of  Dr. 
Conklin’s  retirement  as  delegate,  “.  . . in  good 
times  as  well  as  bad  he  never  failed  the  medical 
organization  with  which  his  name  is  so  closely 
associated.  On  the  contrary,  he  was  a devoted 
and  able  officer  to  whom  the  medical  profession 
is  deeply  indebted.” 


^ “There  were  giants  in  those 

„ days!’’  How  often  we  are  re- 

becomes  • , , r i i -i-  • 

^ • r / minded  of  the  superior  abilities 

Civic  Leader  j 

and  cultural  attainments  of  the 
doctors  of  a generation  or  so  ago.  They  were,  we 
are  informed,  of  more  imposing  stature  in  their 
respective  communities  than  their  modern  proto- 
types. It  was  not  unusual  for  doctors  to  assume 
the  most  important  public  offices  in  the  com- 
munity or  state.  Among  them  were  statesmen, 
public  officials  and  civic  leaders.  But  the  world 
has  changed  and  today  the  doctor  has  little  time 
for  such  things. 

While  much  has  been  written  on  the  subject  of 
the  doctors’  failure  to  accept  their  public  re- 
sponsibilities, little  has  been  said  about  those 
who  do.  Perhaps  there  are  not  as  many  as  in 
former  years,  but  there  are  more  than  is  generally 
recognized.  Recently  one  of  our  members 
emerged  as  a civic  leader  of  no  mean  importance. 
One  would  never  have  guessed  that  Dr.  ].  Ross 


VOL.  XXI,  NO.  4 


Medical  Annals  of  the  District  of  Columbia 


209 


Veal  would  be  the  type  who  could  be  induced  to 
assume  direction  of  the  largest  civic  group  in  the 
District  of  Columbia.  He  is  a quiet-spoken  physi- 
cian, widely  recognized  as  top-flight  in  his  field, 
vascular  surgery.  For  several  years  he  has  been 
one  of  the  Society’s  delegates  to  the  Federation 
of  Citizens’  Associations.  This  year  he  was  chosen 
President  of  the  Federation. 

When  questioned  in  regard  to  accepting  this 
ofiice  he  said  he  believed  it  to  be  the  duty  of  every 
doctor,  no  matter  how  busy  he  was,  to  perform 
some  civic  function.  In  times  as  difficult  as 
these,  he  observed,  the  community  needs  are  ur- 
gent. Even  though  he  maybe  modestly  equipped 
for  leadership,  the  physician’s  specialized  train- 
ing makes  his  services  of  far  more  than  ordinary 
value. 

Dr.  Veal  is,  of  course,  not  alone  in  having  ac- 
cepted the  fact  that  every  citizen  including  the 
physician  owes  his  community  some  of  his  time. 
Other  doctors  who  come  to  mind  are  Drs.  Arthur 
C.  Christie  and  Roy  L.  Sexton,  who  at  different 
times  were  efficient  chairmen  of  the  Board  of 
Trade’s  Committee  on  Public  Health;  Dr.  Her- 
bert P.  Ramsey,  who  served  with  such  distinction 
as  President  of  the  now  defunct  Washington 
Metropolitan  Health  Council;  Drs.  Maurice 
Selinger,  G.  Victor  Simpson  and  A.  Magruder 
MacDonald,  who  are  currently  representing  the 
Society  in  the  District’s  Selective  Service  organi- 
zation; Dr.  Richard  T.  Sullivan,  who  has  for  so 
long  been  an  able  Society  delegate  to  the  Feder- 
ation of  Citizens’  Associations;  and  Dr.  James  A. 
Gannon,  who  has  performed  such  valuable  public 
service  as  a member  of  the  District’s  Board  of 
Education.  There  are  undoubtedly  many  others 
who  belong  on  the  above  list  and  your  Observer 
hopes  he  will  be  forgiven  for  any  inadvertent 
omissions. 

It  is  your  Observer’s  sincerest  hope  that  many 
will  follow  in  the  footsteps  of  Dr.  Veal  and  other 
physicians  who  give  generously  of  their  time  to 
their  communities.  In  the  meantime,  let  no  one 
be  too  hasty  in  concluding  that  there  are  no 
‘‘giants”  in  our  time. 


It  is  a never-ending  source  of 
Partisan  to  your  Observer  that 

Politics  and  , ^ 

doctors  so  frequently  see  news 

about  themselves 


the  Docter 


stories  about  themselves  they 
don’t  like  but  overlook  those  which  would  please 
them. 

An  example  of  the  former  is  the  article  which 
held  the  center  of  the  front  page  of  The 
Evening  Star  for  February  18  describing  the  or- 
ganization of  a national  committee  of  doctors  to 
aid  Senator  Robert  A.  Taft  in  his  drive  for  the 
Presidency.  At  least  half  a dozen  doctors  called 
your  Observer  protesting  what  they  termed  bad 
publicity.  The  AM  A,  whom  they  held  responsible, 
they  said,  should  have  known  better.  Your  Ob- 
server mentioned  the  fact  that  the  Association 
had  no  connection  with  the  committee,  which 
was  to  be  headed  by  Dr.  Ernest  E.  Irons  of 
Chicago,  a former  president  of  the  AMA,  but 
this  didn’t  impress  them  much.  Their  resentment 
was  genuine  and  your  Observer  sensed  their 
feeling  that  the  District  Medical  Society  should 
make  its  views  known  concerning  doctors  par- 
ticipating as  a group  in  partisan  politics. 

In  contrast  to  the  above  an  excellent  article  on 
Medical  Bureau  appeared  in  The  Evening  Star 
for  February  14.  So  far  as  your  Observer  recalls 
he  received  but  one  call  about  this  news  story  and 
that  from  a physician  not  in  private  practice. 

Your  Observer  does  not  presume  to  pass 
judgment  on  the  participation  of  doctors  in  par- 
tisan politics,  but  he  is  of  the  opinion  that  our 
Medical  Society  or  any  medical  organization 
with  like  objectives  should  have  nothing  to  do 
with  efforts  to  advance  the  political  candidacy  of 
any  individual.  In  fact,  to  do  so,  in  his  opinion, 
is  to  invite  justifiable  criticism  and  disunity. 

Every  political  belief  is  represented  in  the 
membership  of  most  medical  societies.  Beyond 
this,  these  societies  are  professional  organizations 
whose  avowed  purj^oses  have  nothing  to  do  with 
partisan  politics.  It  seems  to  your  Observer, 
therefore,  that  there  can  be  only  one  valid  reason 
for  doctors  entering  the  jiolitical  arena  and  that 
is  to  support  or  oppose  policies  which  have  a 
direct  bearing  on  the  welfare  of  their  patients. 


210 


In  and  Out  of  Focus — Observer 


APRIL,  1952 


The  opposition  of  organized  medicine  to  com- 
pulsory health  insurance  is  a case  in  point.  Doc- 
tors and  their  organizations  would  be  derelict  if 
they  did  not  take  a position  on  this  issue. 

But  partisan  politics  is  another  matter.  Your 
Observer  not  only  lent  a sympathetic  ear  to  the 
recent  protests  but  promised  to  mention  them, 
which  he  has  now  done.  Medical  organizations 
would  have  much  to  lose  and  little  to  gain  by  this 
activity.  The  .AMA  is  fully  aware  of  this  and,  so 
far  as  your  Observer  is  aware,  has  never  officially 
given  its  support  to  any  candidate. 

★ 


Seminar  in 
Retrospect 


Those  who  were  responsible 
for  the  first  Midwinter  Seminar 
held  last  February  look  back  on 
this  meeting  with  mi.xed  feelings.  While  in  most 
respects  it  more  than  measured  up  to  their  e.x- 
pectations,  it  was  certainly  not  the  complete 
success  anticipated. 

The  greatest  disappointment  was  the  attend- 
ance. Considering  the  practical  nature  of  the 
program  and  the  care  with  which  it  had  been  pre- 
pared, the  Program  Committee  was  certain  that 
the  Medical  Society  auditorium  would  be  filled 
to  at  least  near  capacity.  But  the  e.xpected  turn- 
out was  never  realized.  The  largest  number  pres- 
ent on  any  occasion  was  125.  Oftener  than  not 
there  were  under  100. 

.\.mong  reasons  advanced  for  the  small  attend- 
ance was  the  prevalence  of  respiratory  illness,  the 
large  number  of  medical  meetings,  the  local 
nature  of  the  program,  and  the  newness  of  the 
venture.  One  can  take  one’s  choice  but  none  of 
these  explanations  is  too  satisfying.  Perhaps  there 
is  some  merit  to  the  observation  that  the  Seminar 
was  a pioneer  undertaking  and  like  all  new 
ventures  will  gain  acceptance  when  its  worth  is 
fully  appreciated. 

The  Committee  was  especially  gratified,  as  it 
should  have  been,  with  the  quality  of  the  pro- 
gram, ])resented  entirely  by  Washington  {ffiysi- 
cians.  It  was  superior  in  every  respect.  As  Presi- 
dent Frank  I).  Costenbader  told  your  Observer 


and  later  wrote  members  of  the  Society,  it  was  a 
“major  league”  meeting  and  “the  papers  would 
do  justice  to  any  national  meeting  which  I have 
attended  in  recent  years.”  He  had  much  praise 
for  Dr.  Darrell  C.  Crain,  Acting  Chairman  of  the 
Committee.  Members  of  the  Committee  were: 
Drs.  Seymour  Alpert,  William  S.  Anderson,  Irvin 
Feldman,  Herbert  S.  Gates,  William  L.  Howell, 
Paul  Kiernan,  David  H.,  Kushner,  Arthur  A. 
Morris,  Jr.,  William  R.  Stovall  and  Jacob  J. 
Weinstein. 

Due  to  unavoidable  circumstances.  Dr.  Ed- 
ward B.  Tuohy,  Chairman  of  the  Program  Com- 
mittee, was  inactive  except  to  preside  at  one 
session  during  the  Seminar. 

The  suggestion  has  been  made  that  it  might  be 
desirable  for  the  Society  to  return  to  its  Wednes- 
day night  meetings.  However,  there  is  no  evi- 
dence that  attendance  would  be  better  than  in 
the  past  several  years.  It  would,  therefore,  seem 
wise  to  continue  experimentation  with  the  Semi- 
nar. Your  Observer  has  a feeling  that  the  e.xcel- 
lent  reports  on  the  initial  effort  have  gotten 
around  and  that  next  year  it  will  be  a different 
story. 

★ 


“Pen  Pushers 


“Now,  to  get  to  the  theme  of 

, this  evening’s  session.  My  sub- 

and  Pill  . . , , , 

Peddlers  ” pen-pushers  and  pill-ped- 

dlers — blood  brothers!  I see 
many  of  you  flinch,  just  as  I do  when  one  of  you 
aims  that  needle  and  in  a sugary  voice  says,  ‘This 
isn’t  going  to  hurt  at  all,  old  man.’  Then  three 
days  later,  I can  move  my  arm  again!  But, 
seriously,  gentlemen,  you  medics  and  we  ink- 
slingers  do  have  a lot  in  common.” 

Thus  with  mock  seriousness  did  lean,  dry  Jim 
Berryman,  cartoonist  for  the  Washington  Evening 
Star,  address  himself  to  members  of  the  Medical 
Society  and  the  Woman’s  .Auxiliary  on  the  oc- 
casion of  their  joint  meeting  in  the  Aledical 
Society  auditorium  on  February  21.  Air.  Berry- 
man hastened  to  explain  his  “blood  brothers” 
theorv  as  follows: 


“For  instance:  A'ou  can’t  start  prescribing  for  a jja- 


Photos  by  Leslie  H.  French,  M.D. 

SPEAKERS  IN  ACTION  AT  FIRST  MIDWINTER  SEMINAR 


(1)  I)R.  Sol  Katz,  addressing  the  first  session  of  the  Midwinter  Seminar;  (2)  Dr.  W allace  M.  Yater,  Moderator  for 
a Panel  Discussion  on  Xew  Drugs;  (.3)  Dr.  W illiam  L.  Howell;  (4)  Dr.  Donald  Stubbs;  (5)  Dr.  Darrell  ('.  Crain,  .\ct- 
ing  Chairman  of  the  F'rogram  Committee,  which  [ilanned  the  Seminar,  [iresiding  at  the  opening  session;  (6)  Dr.  Jacob  J. 
Weinstein;  (7)  Brig.  General  Sa.m  F.  Seeley,  .MC,  US.V,  Walter  Reed  .Vrmy  Hos|)ital;  (8)  Dr.  Calvin  'P.  Klopp;  (9)  Dr. 
Paul  Kiernan;  (10)  Dr.  Joseph  M.  Barker;  (11)  Dr.  John  W.  'Frenis;  (12)  Dr.  Hugh  H.  Hiissey.  .Ml  of  the  speakers  for 
the  Midwinter  Seminar  were  physicians  from  Washington  and  vicinit\-,  and  all  of  those  shown  here,  with  the  exception  of 
General  Seeley,  are  memhers  of  the  District  Medical  Society. 


211 


212 


hi  and  Out  of  Focus — Observer 


APRIL,  1952 


tient  until  you  diagnose  his  ailment.  We  can’t  lampoon 
a politician  until  we  analyze  his  motives.  Now,  of  course, 
we  have  one  distinct  advantage  over  you  in  this  field. 
We  make  mistakes  too,  but  when  we  flub  one,  the  worst 
we  do  is  put  a few  dents  in  his  ego  and  he’s  as  good  as 
new  when  the  ne.xt  campaign  rolls  around! 

“One  of  the  primary  points  of  affiliation  between  the 
medical  profession  and  cartoonists  is;  It  takes  so  many 
years  of  preparation  and  near-starvation  before  they 
become  specialists.  Yes,  I know  a doctor  starts  out  at 
the  tender  age  of  3 or  4 inspired  with  a great,  shining 
light  of  philanthropic  desire  to  administer  to  the  world’s 
physical  ills,  and  he  doesn’t  deviate  one  student  nurse 
from  his  goal.  The  cartoonist,  as  a rule,  doesn’t  hew  to 
the  line  quite  as  objectively,  but  the  great  incentive  is 
still  burningly  present  ...  he  wants  to  eat  too!’’ 

Turning  to  his  own  field,  he  recalls; 

“During  my  early  days,  I wandered  off  into  other 
fields  of  endeavor.  I had  brief  flings  at  ranching,  forestry, 
irrigation  work,  selling,  and,  during  one  brief  period  of 
low  funds,  I found  a restaurant  job  highly  satisfactory- 
three  times  a day.  I finally  landed  a reporting  berth  with 
a Southwestern  paper.  This,  on  top  of  my  other  sorties 
into  the  world  of  business,  filled  in  a lot  of  education 
and  very  fast. 

“While  less  than  10  per  cent  of  .America’s  cartoonists 
started  out  as  reporters,  the  other  90  per  cent  plus  wish 
they  had.  To  have  served  even  a brief  stretch  as  a story- 
getter  and  teller  teaches  a newsman  how  to  look  for  news 
and  how  to  recognize  it  when  he  finds  it.  Reporting  is  a 
deluxe  school  for  hopeful  cartoonists. 

“But  during  the  17  years  I’ve  been  a political  car- 
toonist, I’ve  never  been  able  to  stick  my  pen  into  a Re- 
publican .Administration!  Not  that  I’m  anti-Democrat. 
No!  I’m  just  anti-5  percenters,  mink-coaters,  deep- 
freezers,  RFCers,  free  Florida-trippers  and  tax-fixers. 
.And  I firmly  believe*  that  there  are  47  other  states  be- 
sides Missouri  capable  of  producing  leaders  and  states- 
men. (A'ou  remember  that  old  saying,  ‘A'ou’ve  got  to 
show  me,  I’m  from  Missouri!’  It’s  been  changed  in  the 
last  5 or  6 years;  now  they  say.  Til  show  you  . . . I’m 
from  Missouri!) 

“A'ou  know,  some  of  my  critics  have  tagged  me  a 
‘crusader’.  Well,  now  if  they  thought  they  were  ridicul- 
ing me,  it  certainly  backfired.  I like  it!  1 very  much  like 
being  a crusader  for  .American  principles.  The  term  free 
press  is  closely  allied  to  freedom  of  speech.  I feel  sure 
everyone  here  will  agree  with  me  when  I say  that  the 
newspapers  and  magazines  of  this  country  must  never 
be  the  instruments  of  Government  policy.’’ 

But  Mr.  Berryman  could  not  be  serious  for 


long.  Here  he  ribs  the  doctors  again: 

“Speaking  of  specialists,  now,  there’s  where  you  fel- 
lows have  leaped  ahead  of  the  cartoonists.  Thirty  or 
forty  years  ago,  one  good  old  family  doc  handled  the 
situation  from  cradle  to  grave.  But  of  course  that  was 
before  cardiology,  neurology,  endocrinology,  gastroen- 
terology, and  so  on.  (If  I pronounced  any  of  those  words 
correctly,  it  is  pure  coincidence.)  So,  of  course,  today’s 
medical  man  has  to  channel  his  practice  to  be  on  such 
familiar  terms  with  his  special  line  that  he  can  tell  his 
patient  what  a wonderful  disease  he  has  been  privileged 
to  contract. 

“But